Administration on Aging Performance Measurement Toolkit · home- and community-based services in state long-term care plans. Considering these contextual factors is essential when

Administration on Aging

Performance Measurement Toolkit

AcknowledgementsContract No. 233-02-0087 supported the development of the Toolkit.

The Performance Outcome Measurement Project (POMP) grantees that represented the State Units on Aging and Area Agencies on Aging, with their providers, university and other research partners, collaborated with the Administration on Aging through a cooperative grant program to develop and test the contents of the Toolkit. The grantees spent many years refining and testing the products and survey instruments. This Toolkit represents the fruits of their hard work. We would like to thank the following agencies for their participation in POMP:

State and Area Agencies on Aging from the following states:

Arizona

California

Delaware

Florida

Georgia

Illinois

Indiana

Iowa

Massachusetts

New York

North Carolina

Ohio

Oklahoma

Rhode Island

South Carolina

University and other research organizations:

Aha! Inc.

Arizona State University, Phoenix, AZ

Finger Lakes Geriatric Education Center, Rochester, NY

Hana Research Group, Stow, OH

Scripps Gerontology Center, Miami University, Oxford, OH

University of Georgia, Athens, GA

University of North Carolina at Chapel Hill

University of North Florida, Jacksonville, FL

Westat, Rockville, MD

Table of Contents

Introduction Chapter 1

Measure Program Performance Through Survey Data Chapter 2

Select the Survey Instrument Chapter 3

Determine the Data Collection Method Chapter 4

Develop the Work Plan and Budget Chapter 5

Select the Service Recipient Sample Chapter 6

Administer the Survey Chapter 7

Enter, Review, and Analyze the Data Chapter 8

Prepare the Report and Disseminate the Results Chapter 9

Compare the Results to Other National Surveys Chapter 10

Survey Instruments (Mail and Telephone) Appendix A

Caregiver Services

Case Management

Congregate Meals

Home Delivered Meals

Transportation

Additional Services Received Module

Demographics Module

Physical Functioning and Health

Social and Emotional Well-Being

Supplemental Materials Appendix B

Catawba County Council on Aging Sample Letter of Invitation

ConfidentialityAgreement

Establishing Contact

Script for Interviewers to Use for Answering Machines or Voice Mail

Sample List and Results and Telephone Interviewer Caller Log

POMP Survey Contact Sheet

Sample instructions for POMP Survey Interviewers

Reminder/Thank You Post Card

NewYorkStateOfficefortheAgingReminderLetter

Ohio Department of Aging, Analysis of Surveys: Senior Farmers Market Nutrition Program

Pass It On Newsletter

Report to the NCDOT Public Transportation Division’s Human Services Transportation Council

Amber River Area Agency on Aging Annual Report

Memo to In-home Aide Providers

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1. Introduction

Introduction The Administration on Aging (AoA), U.S. Department of Health and Human Services, supported the Performance Outcome Measurement Project (POMP) to develop tools and procedures to measure the impact of programs funded under the Older Americans Act (OAA). POMP was a collaborative effort between AoA and grantees that represented State Units on Aging (SUAs) and Area Agencies on Aging (AAAs), with their providers and university research partners, from across the country. The Performance Measurement Toolkit is the culmination of the grantees’ development efforts and provides step-by-step instructions on how to use POMP survey instruments to measure the performance of key AoA-funded services and use the results for program improvement.

The POMP tools represent an effective combination of scholarly research and practical experience. Professional researchers provided conceptual models of performance measurement to assist in the planning and design of service recipient surveys by agencies participating in POMP. Over several years, service system professionals have reviewed, tested, and revised these survey instruments, tools, and procedures.

In addition to providing individual State and Area Agencies on Aging with performance measures, many of the items in the POMP survey instruments are also included in the AoA National Surveys of Older Americans Act Participants (NSOAAP). This makes it possible to compare findings on the state and local level to those of the National Surveys. The National Survey data and other benchmarks for comparison are located on the AGing Integrated Database (AGID) website at http://www.data.aoa.gov.

This Toolkit is divided into several chapters, each covering an important step in the process of measuring the performance of state and community programs on aging, as illustrated in the Performance Measurement Process Diagram.

http://www.data.aoa.gov

1-2

Performance MeasurementProcess Diagram

Select the Survey Instrument

Determine Best Data Collection Method

Develop a Work Plan and Budget

Select the Client Sample& Administer Survey

Enter, Review & Analyze Data

Prepare Report &Disseminate Results

2-1

2. Measure Program Performance Through Survey Data

Performance measurement data is useful for:

•

•

•

monitoringandimprovingthequalityofservices;

examiningtheeffectofservicesonrecipients;and

providingempiricalevidenceonwhichtobaseprogramimprovementsandfundingdecisions.

The Older Americans Act (OAA) services system consists of many componentswithcomplexinterrelationships.Whileasimple,linearmodelcapturesonlysomeofthiscomplexity,thediagramonpage2-3illustratesseveralaspectsoftheOAAnetworkthatareimportanttomeasure.Thisnetworklogicmodelconsistsofinputs,ortheunderlyingmission,enablingfundingandotherresourcesonwhichthenetworkrelies.Theresourcessupportarangeofactivities,specificallythe process ofprogramoperationsandservicedelivery.Outputs consistofthoseinitialresults,suchasthenumbersandcharacteristicsofpersonsreceivingservices,theamountofservicestheseindividualreceive(suchasthenumberofhome-deliveredmealsorotherserviceunits),orsuccessfulcompletionofsuchinitiativesasimprovementintheefficiencyofprogramoperations.Mostimportantismeasuringthe outcomes or the impactthatserviceshaveonthewell-beingofolderpersonssuchasremaininginthecommunityandavoiding(ordelaying)nursinghomeplacement.ThisistheprimaryfocusoftheperformancemeasuresandguidanceinthisToolkit.

Thefindingsfromperformancemeasurementcanhelprefineandimprovemanyaspectsoftheservicedeliverysystem,asillustratedbythe feedbackloopinthediagram.Finally,theOAAservicessystemoperatesinanenvironment thathasasubstantialinfluenceonthedevelopmentanddeliveryofservicesfortheaging,suchasnursinghomepre-admissionscreeningrequirementsandtheemphasisonhome-andcommunity-basedservicesinstatelong-termcareplans.Consideringthesecontextualfactorsisessentialwheninterpretingandapplyingthefindingsfromperformancemeasurement.Forexample,increasingthelengthoftimeolderpersonsliveindependentlyinthecommunitycanbeafunctionofOAAhome-andcommunity-basedservices.Butalsoinfluentialarethecaretransitionsystemsofhospitalsthatmayaffectpost-acuteandlong-termcareplacementoptionsanddecisionsforolderpersons.

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MonitorQualityandImproveServicesRecipientassessmentofservices,theprimaryfocusofthisToolkit,isaveryimportantpartofmeasuringprogramandservicequality.Theresultsofsurveysprovideinformationontheextenttowhichpeopleusetheservice,thequalityoftheserviceitself,andself-reportedoutcomes.Forinstance,home-deliveredmealsrecipientsareabletoassessthefoodintermsoftemperature,taste,andsmellaswellasthetimelinessofthedelivery,allofwhichareindicatorsoftheservicequality.

Theresultsofrecipientsurveyscandocumenttheimpactofservicesfromtheservicerecipients’perspective,andtheymayalsoidentifyareasinwhichachangeinserviceswouldbettermeettheneedsoftherecipients.

Document the Effect of Services onServiceRecipientsMostpeoplewhoworkinthefieldofagingwanttoknowtheeffecttheirworkhasonservicerecipients’livesinadditiontothenumberandcharacteristicsofthepeopleserved.TheywanttoknowiftheserviceshavehelpedolderAmericansremaininthecommunity,orwhetherreceivingserviceshashelpedcaregiverssupporttheirelderlyfamilymembers.SelectedsurveyitemsintheToolkitaskforself-reportedoutcomes;forinstance,theTransportationSurveyinstrumentincludestheitem:“Doyougetaroundmorethanyoudidbeforeyouhadthisservice?”

Provide Evidence of EffectivenessAnincreasingnumberoffundingagenciesrequireperiodicreportingofperformancemeasurementdata,includingprograminputs,activities,outputs,andoutcomes.Ameasureofservicerecipientoutcomes(i.e.,howthoseservicesactuallyhelpedthepeoplewhoreceivedthem)alongwithprogramoutputs(e.g.,thenumberofmeals,thenumberofridesthathavebeenprovided,etc.)areoftenrequiredoffundingagencies.Theresultsofsurveyswillassistagenciestorespondtotheaccountabilityrequirementsthatoftenaccompanytheirbudgetrequests. Forexample,theAoAusesacombinationofsurveyresults,incorporatingmanyoftheToolkitmeasures,andoutputdatainitsCongressionalbudgetrequests.

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Performance Measurement Logic Model

Process PlanningProgram developmentManagementStaffingContractingOther activities

OutputsPersons servedService units deliveredInitiatives completedOther measures of activity

OutcomesIndependent livingQuality of lifeOther impacts

Inputs Funding LegislationMissionInfrastructureOther resources

Feedback

Environment Long-term care policies Community wealth/povertyOther contextual factors

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3. Select the Survey Instrument

This Toolkit contains nine survey instruments to assess programs and to learn about service recipients. The survey instruments are designed to be administered by telephone; however, it is possible to administer them by mail, or, in the case of congregate meals, in person. The POMP grantees field-tested and refined these survey instruments over several years, and they conducted reliability and validity testing to ensure they were psychometrically sound.

Table 3-1. POMP Survey Instruments

Types Names

Field-Tested Survey Instruments for Five Services*

•

•

•

•

•

Caregiver Services

Case Management

Congregate Meals

Home-Delivered Meals

Transportation

Cross-Cutting Modules Instruments about Service Recipients’ Characteristics that Can Accompany the Service-Specific Instruments

•

•

•

•

Additional Services Received

Demographics

Physical Functioning and Health

Social and Emotional Well-Being

*The workgroup also developed survey instruments for additional services that did not have the benefit of complete testing. These covered information and referral/assistance and senior centers.

For the information and referral assistance report see http://elderaffairs.state.fl.us/doea/evaluations_0003.php

For the senior center report please see http://elderaffairs.state.fl.us/doea/sc_toolkit.php

http://elderaffairs.state.fl.us/doea/evaluations_0003.php

http://elderaffairs.state.fl.us/doea/evaluations_0003.php

http://elderaffairs.state.fl.us/doea/sc_toolkit.php

http://elderaffairs.state.fl.us/doea/sc_toolkit.php

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Assessing Specific Programs and/or Services

Caregiver Services Survey InstrumentThe core Caregiver Services Survey Instrument has 16 questions. The topics covered are services received, service quality, and service impact on the caregiver and care recipient. In addition, the survey instrument includes seven optional modules.

(To view the Caregiver Services Survey Instrument, see Appendix A.)

Table 3-2. Comprehensive Survey Modules on Caregiver Satisfaction and Outcomes

Modules Names Number of Questions

A Care Provided 5

B Burdens and Rewards of Caregiving 4

C Impact on Employment 4

D Health of Caregiver 2

E Demographics 14

F Health and Physical Functioning of Care Recipient 15

G Service and Information Needs 2

Case Management Survey InstrumentThe Case Management Survey Instrument has 20 questions. The topics covered are quality of service and the extent to which the case management service helped the service recipient receive needed care.

(To view the Case Management Survey Instrument, see Appendix A.)

Congregate Meals Survey Instrument The Congregate Meals Survey Instrument has 51 questions about frequency of program participation, food intake, service quality, self-reported outcomes, nutrition education and food security.

(To view the Congregate Meals Survey Instrument, see Appendix A.)

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Home-Delivered Meals Survey InstrumentThe Home-Delivered Meals Survey Instrument has 47 questions about the frequency of program participation, food intake, service quality, self-reported outcomes, and food security.

(To view the Home-delivered Meals Survey Instrument, see Appendix A.)

Transportation Survey InstrumentThe Transportation Survey Instrument has 27 questions. The topics covered are frequency of and reason for use, overall experience with service, service quality, self-reported outcomes, and ease of access to transportation.

(To view the Transportation Survey Instrument, see Appendix A.)

Cross-Cutting ModulesThe cross-cutting modules focus on service recipient characteristics and well-being. These instruments allow agencies to make comparisons between service recipients’ characteristics at the local level with AoA National Survey data or to see if responses to self-reported service outcomes vary by demographic, frailty, or other factors. These modules may be used in conjunction with any of the previously discussed survey instruments and are administered by telephone, mail, or in-person.

(To view the Cross-Cutting Modules, see Appendix A.)

Demographics ModuleThe Demographics Module has ten questions related to gender, age, race, marital status, and income, and they follow standard wording used in many national surveys.

(To view the Demographics Module, see Appendix A.)

Physical Functioning and Health ModuleThe Physical Functioning and Health Module has 21 questions. The topics covered are self-assessment of health, limitations in activities of daily living and instrumental activities of daily living, and use of one or more assistive devices (e.g., walker, wheelchair, hearing aid).

(To view the Physical Functioning and Health Module, see Appendix A.)

3-4

Social and Emotional Well-Being Survey ModuleThe Social and Emotional Well-Being Module has seven questions. The topics covered are frequency of contact with other people, frequency of leaving home for social activities, self-assessment of emotional well-being, and frequency of negative feelings (e.g., stress, grief, worry) and their impact on participation in social activities.

(To view the Social and Emotional Well-Being Module, see Appendix A.)

Additional Services Received ModuleThe Additional Services Received Module has 20 questions. The topics covered are receipt of other services and self-reported outcomes associated with the receipt of these services.

(To view the Additional Services Received Module, see Appendix A.)

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4. Determine the Data Collection Method

IntroductionSelecting the appropriate mode of data collection for a survey is dependent on three factors: (1) the objectives of the survey, (2) the concepts to be measured, and (3) the population. In addition, the timeframe available for data collection and the budget influence the mode of data collection. Survey instruments can be either self-administered or interviewer-administered. Data collection modes range from in-person, telephone, mail, to the Internet.1

The response rates often differ markedly by mode. In-person surveys usually produce the highest response rates, followed by telephone and mail, respectively. If a high response rate is desired, in-person or telephone surveys are the best data collection modes, but the costs are higher than for mail surveys.

When selecting the mode of data collection, it is also important to remember that the majority of respondents are older persons. For mail surveys, ensure that written questionnaires have a font size that is readable for older persons who may have vision problems. For in-person and telephone surveys, it is necessary for interviewers to speak clearly and to make sure that respondents are able to hear the questions. Additional information on interviewing older persons is in chapter 7.

1 An excellent resource for conducting telephone, mail, internet, and mixed mode surveys is Dillman, D., Smyth, J. & Melani, L. (2008). Internet, Mail and Mixed Mode Surveys. Hoboken, New Jersey: John Wiley.

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In-Person SurveysIn-person surveys allow the interviewer to build rapport with the re-spondent. Often, respondents may feel ill at ease, and a well-trained interviewer can make them feel comfortable by clearly explaining the purpose of the study and the specific topics covered. Complex inter-views are best administered in-person. Interviewers are able to probe for more complete responses when necessary and observe body lan-guage during the interview.

In-person surveys require interviewers who are trained on how to administer questionnaire items, their meaning, when to probe and how to respond to frequently asked questions. One limitation of in-person surveys is that respondents may give socially desirable responses, es-pecially to questions on sensitive topics. Another consideration is that in-person surveys take time to administer, especially when respon-dents are not located in close proximity. Therefore, budgeting for an in-person survey should include costs for not only interviewer time for administering the questionnaire, but also for traveling and for travel expenses, such as gas and vehicle upkeep.

Telephone SurveysUsing telephone surveys allows multiple interviewers to conduct the survey in a relatively short period of time. Additionally, computer-assisted telephone surveys accommodate complicated skip patterns. Moreover, interviewers are available to respond to frequently asked questions and probe according to the data collection protocol. Qual-ity control measures, such as monitoring interviewers during survey administration, ensure that interviewers adhere to the study protocol.

The optimal length of telephone interviews is 20 to 30 minutes. As with in-person surveys, telephone interviewers need training on how to administer the questionnaire, answer respondents’ questions, and how to handle difficult situations. Having to deal with missing or inaccurate phone numbers may increase the level of effort needed to complete a telephone survey. In recent years, there has been a diminishing return rate for telephone surveys due to screening calls. This is an important limitation that reduces the cost effectiveness of telephone surveys.

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Mail SurveysMail surveys are less intrusive than in-person or telephone surveys, especially when asking for sensitive information. Respondents are able to answer at a convenient time for them. Mail surveys are less expen-sive than in-person and telephone surveys. Telephone numbers are not necessary, but accurate lists of addresses are needed. With a mail survey, there is no interviewer support, but mail surveys often include a toll-free number for respondents to call for additional information. If doing a mail survey, insure that you provide time for respondents to return their completed interviews. In addition, nonrespondents can be called or sent postcard reminders to participate.

Some limitations of mail surveys include the following: they are not conducive to complex questions; there is no control over who really completes the questionnaire; and the turnaround time for completion is much longer than for in-person and telephone surveys. The response rates for mail surveys are often dramatically lower than for in-person and telephone surveys.

Internet SurveysInternet surveys have become more popular in the last few years. They have some advantages, such as the ability to handle complex skip patterns, the use of visual stimuli to guide respondents, and elimination of data entry. While increasing numbers of older adults are using the internet, Older Americans Act clients who tend to be older, poorer, and frailer may be less likely than their healthier and wealthier counterparts to have such access.

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5. Develop the Work Plan and Budget

The survey planning process involves developing a schedule and budget to ensure that the survey is completed on time and within the allocated resources. Prior to conducting a survey, identify specific dates for the period of performance for each task. This will ensure that the survey is completed within the allowed timeframe. Tables A and B contain samples of schedules for a telephone and mail survey, respectively.

Most agencies that conduct surveys of clients have a specific budget allocation for sampling, data collection, data entry, analysis, and report preparation. There is always a tradeoff between the desired procedures and the available funds. Prior to finalizing the design of a survey, develop a budget with a line item for each task. Ensure that costs are realistic. For instance, if an agency is conducting a telephone survey, make sure that the interviewer hours include enough time to contact service recipients more than once in case the sampled person is not at home on the first or second try. That will ensure that the agency is able to implement the survey design and procedures within the allocated funds. Tables C and D contain samples of spreadsheets for estimating costs for each line item. Tables E and F contain samples of budget sheets for conducting telephone and mail surveys, respectively.

Clear Steps at the Survey Planning Stage

Survey Planning Process:

1 23

45

76

8Plan

Sample

Pilot

Survey

PrepareData

Analyze Data

DisseminateResults

PrepareReport

5-2

Clear Steps to a Successful Telephone Survey

Telephone Survey Work Plan:

1. Plan

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•

•

•

•

•

Determine purpose of the survey

Select appropriate survey instrument

Determine the methodology

Design data collection procedures

Develop cost estimate

Determine staff needs

2. Sample

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•

•

•

•

Identify population

Specify sample selection criteria

Identify sampling procedure

Identify source of information for sampling

Draw sample

3. Pilot

• Test procedures and revise according to the results of testing

4. Survey

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•

•

•

•

•

Notify selected agencies (if sample is drawn from another agency)

Prepare materials: client pre-notification letter

Prepare call sheets

Select interviewers

Train interviewers

Conduct telephone survey

5. Prepare Data

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•

•

•

Enter data

Check for accuracy of data entry

Review database for outliers and anomalies in the data

Code responses to open-ended questions

6. Analyze Data

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Run descriptive statistics

Analyze responses to open-ended questions

7. Prepare Report

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Prepare draft report

Submit report to reviewers

Revise report

8. Disseminate Results

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•

Develop plan for sharing results

Disseminate report

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Clear Steps to a Successful Mail Survey

Mail Survey Work Plan:

1. Plan

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•

•

•

•

•







2. Sample

•

•

•

•

•

Identify population




Draw sample

3. Pilot

• Test procedures and revise according to the results of testing

4. Survey

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•


Prepare materials: cover letter, copies of survey instruments, envelopes for mailing and returning survey instruments

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•

•

Mail survey materials

Enter data into an electronic data entry utility as completed instruments are returned

Contact nonrespondents at designated time periods

5. Prepare Data

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•

•

•

Enter remaining data




6. Analyze Data

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•

Run descriptive statistics


7. Prepare Report

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•



Revise report

8. Disseminate Results

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•

Develop plan for sharing results

Disseminate report

5-4

A. Schedule for a Telephone Survey

Step Key Tasks Lead Time Frame in Weeks1 2 3 4 5 6 7 8 9 10 11 12

Plan







Sample

Identify population




Draw sample

Pilot Test procedures and revise according to the results of testing

Survey


Prepare materials: client prenotification letter

Prepare call sheets

Select interviewers

Train interviewers

Conduct telephone survey

Prepare Data

Enter data




Analyze DataRun descriptive statistics


Prepare and Disseminate

Report



Revise report

DisseminateDevelop plan for sharing results

Disseminate report

5-5

B. Schedule for a Mail Survey

Step Key Tasks Lead Time Frame in Weeks1 2 3 4 5 6 7 8 9 10 11 12

Plan







Sample

Identify population




Draw sample

Pilot Test procedures and revise according to the results of testing

Survey


Prepare materials: cover letter, copies of survey instruments, envelopes for mailing and returning survey instruments

Mail survey

Enter data into an electronic data entry utility as survey instruments are returned


Prepare Data





Analyze DataRun descriptive statistics


Prepare and Disseminate

Report



Revise report

DisseminateDevelop plan for sharing results

Disseminate report

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C. Cost Estimates for Collecting Data by TelephoneTELEPHONE SURVEY - COST ESTIMATES

Step Item/Activity Sub-Com-ponents

Estimating the Cost Notes

Plan Staff time ___ days @ $___ per day

Staff involvement will vary depending on size of agency.

Sample Staff time ___ days @ $___ per day

If data is in a centralized database, allot time for preparing the code for data extraction. If data needs to be obtained from local providers, allot time for that type of activity and for creating a combined database.

Mailouts

Paper ___ packages @ $___ per ream

While it is not absolutely necessary to send a pre-survey letter, it does improve the response rate and create trust.

Printer cartridge/toner

___ packages @ $___ per package If not a part of agency overhead.

Address Labels

___ packages @ $___ per package

Labels are unnecessary if you are using window envelopes and properly fold the letter.

Envelopes ___ packages @ $___ per package

Be sure they accommodate all materials being enclosed.

Mail out preparation

___ hours @ ___ per hour

Include folding, stuffing, stamping, labeling and mailing activities.

Postage ___ Surveys @ $___ per package

You will need to send out about four times the number of completed surveys you need for your analysis.

Pilot Test

Staff time ___ hours (or days) @ $___ per hour (or days)

Include time for preparation, mailout, and analysis.

MaterialsUse mailout budget items above

See Above (Mailout) Items

Limited materials for small survey mailout.

Revise Staff time ___ hours @ ___ per hour Update plan based on pilot test.

Survey

Notify service recipients

Staff time for mailout


Notify clients - materials

Use mailout budget items above

See Above (Mailout) Items

Include all items in (Mailouts) section above.

Call sheet preparation Staff time ___ days @ $___

per day Lists of clients for interviewers to call.

Survey calls Interviewer training

___ Calls per hour X ___

Training time will depend on the experience of the interviewers. Even experienced interviewers need training for specific surveys.

Survey calls Interviewer call time


During the Pilot, you can determine the length of the call. Estimates are also provided on the Toolkit you choose. Be sure to build in time for calls that are attempted but not completed.

Prepare Data

Data entry ___ hours @ ___ per hour

Separate data entry is needed only if you do not have data entry being completed while the call is made.

Data cleaning ___ hours @ ___ per hour

Proof read and check for accurate coding.

Merge files, verify data ___ hours @ ___

per hourMerge if data are in multiple files. Verify that all data are correct.

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TELEPHONE SURVEY - COST ESTIMATES



C. Cost Estimates for Collecting Data by Telephone (continued)

Analyze Data

Staff time

The cost of the analysis will depend upon what level of detail is needed for the report. Allow 2 – 4 weeks for a brief analysis and up to 1-2 months for a very detailed report.

MaterialsPurchase data analysis software

Access, Excel, SPSS, or SAS

Report

Preparing the report Staff time ___ hours @ ___

per hourOnce the analysis is complete, the report can be prepared in approximately 2 weeks.

Reviewing the report Staff time ___ hours @ ___

per hour Include staff time for editing.

Printing the report

Staff time ___ hours @ ___ per hour

Materials The cost of in-house printing varies greatly from a commercial printer.

Disseminate

OPTIONS

Costs will vary dramatically depending upon how the information is shared.

Website

Email Interoffice

Postal Service Postage ___ Reports @ $___ per package

Group meetings

Conferences

Additional Costs

5-8

D. Cost Estimates for Collecting Data by MailMAIL SURVEYS - COST ESTIMATES



Plan Staff time ___ days @ $___ per day

The survey plan includes selecting service, determining method to survey, and evaluating resources. Staff involvement will vary depending on size of agency.

Sample Staff time ___ days @ $___

per day

If client information is in a centralized database, allot time for selecting sample. If client information must be obtained from local providers, include time for obtaining information and creating a combined database.

Mailouts

Paper ___ packages @ $___ per ream

Printer cartridge/toner

___ packages @ $___ per package If not a part of agency overhead.

Address labels

___ packages @ $___ per package

Labels are not needed if you are using window envelopes and properly fold the letter.

Envelopes ___ packages @ $___ per package

Be sure they accommodate all materials being enclosed. Remember return envelopes for mail surveys.

Survey Scan forms ___ packages @ $___ per package

This option is only for those who are considering using scannable forms as a means to enter the data rather than manual data entry.

Follow-up

Mail out preparation


Include folding, stuffing, stamping, labeling, and mailing activities.

Postage ___ Surveys @ $___ per package

An agency will need to send out about four times the number of surveys needed for its analysis. Remember to include postage paid return envelopes for mail surveys.

Pilot

Staff time ___ hours (or days) @ $___ per hour (or days)

Include time for preparation, mail out, and analysis.

MaterialsUse mail out budget items above

See above (mail out) items

Limited materials for small survey mail out.

Revise Staff time ___ hours @ ___ per hour Update plan based on Pilot.

Survey

Survey - staff Staff time for mail out


Survey - materials

Use mail out budget items above


Include all items in (mail outs) section above.

Follow-up/staff Staff time for mail out


This step is unnecessary if response rate from the initial survey is sufficient.

Follow-up/materials

Use mail out budget items above


Include all items in (mail outs) section above.

Follow-up telephone calls

Interviewer Call time


In many cases, a followup phone call after a mailing can increase the response rate of a survey.

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D. Cost Estimates for Collecting Data by Mail (continued)

MAIL SURVEYS - COST ESTIMATES



Prepare Data

Data entry ___ hours @ ___ per hour

Enter data into spreadsheet or statistical software. If using scanning software, the cost is for managing the scanning process.

Data cleaning ___ hours @ ___ per hour Proofread and check for accurate coding.

Merge files, verify data


Merge data if entered into multiple spreadsheets or databases. Verify that all data are correct.

Analyze Data


The cost of the analysis will depend upon what level of detail is needed for the report. Allow 2–4 weeks for a brief analysis and up to 1–2 months for a very detailed report.

MaterialsPurchase data analysis software?

Item cost Access, Excel, SPSS, or SAS

Prepare Report

Preparing the report Staff time ___ hours @ ___

per hourOnce the analysis is complete, the report can be prepared in approximately 2 weeks.

Reviewing the report Staff time ___ hours @ ___

per hourAn agency may want to include the staff time for editorial or content review.

Printing the report


Materials

If preparing a formal, printed report, and the agency does not have in-house capacity, request a bid from a professional printer. In-house printing will be sufficient for most reports, especially if a color printer is available.

Disseminate

Web site

Costs will vary depending upon how the information is shared.

Email

Interoffice

Postal service Postage ___ Reports @ $___ per package

Group meetings

Conferences

Additional Costs

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E. Develop a Budget for Collecting Data by Telephone

TELEPHONE SURVEY - COST ESTIMATES

Step Item/Activity Sub-ComponentsInsert

Number or Count Here

Cost per Unit or Hour

Total(Formula

Cells -- Do not Overwrite)

Plan Staff time $0.00

SampleStaff time $0.00Outsourced sampling $0.00

Pilot

Staff time $0.00

Notifications, pilot test and survey

Paper $0.00Printer cartridge/toner $0.00Address Labels $0.00Envelopes $0.00Mail out preparation $0.00Postage $0.00

Revise Staff time $0.00

Survey

Notify clients - staff Staff time for mailout $0.00

Notifications - mail out


Call sheet Preparation Staff time $0.00Survey calls Interviewer training $0.00Survey calls Interviewer call time $0.00Cost for telephone charges $0.00

Prepare Data

Data entry $0.00Data cleaning $0.00Merge files, verify data $0.00

Analyze DataStaff time $0.00

Materials Purchase data analysis software $0.00

Report

Preparing the report Staff time $0.00Reviewing the report Staff time $0.00

Printing the reportStaff time $0.00Materials $0.00

Disseminate

Website $0.00Email $0.00Interoffice $0.00Postal service Postage $0.00Group meetings $0.00Conferences $0.00

Additional Costs $0.00

Grand Total $0.00

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F. Develop a Budget for Collecting Data by MailMAIL SURVEYS - COST ESTIMATES

Step Item/Activity Sub-ComponentsInsert

Number or Count Here

Cost per Unit or Hour

Total(Formula

Cells -- Do not Overwrite)

Plan Staff time $0.00

Sample Staff time $0.00

Pilot

Staff time $0.00

Mail pilot test


Revise Staff time $0.00

Survey

Survey - staff Staff time for mailout $0.00

Full Survey - Materials for mail out


Follow-up - staff Staff time for mailout $0.00

Follow-up - materials for Mail Out (Optional)


Prepare Data

Data entry $0.00Data cleaning $0.00Merge files, verify data $0.00

Analyze DataStaff time $0.00

Materials Purchase data analysis software $0.00

Report

Preparing the report Staff time $0.00Reviewing the report Staff time $0.00

Printing the reportStaff time $0.00Materials $0.00

Disseminate

Website $0.00Email $0.00Interoffice $0.00Postal Service Postage $0.00Group meetings $0.00Conferences $0.00

Additional Costs $0.00

Grand Total $0.00

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6. Select the Service Recipient Sample

The Toolkit contains a Sample Size Calculator to help agencies determine the number of service recipients out of the population of interest that need to complete a survey instrument (see Table 6-1). The sample size needs to be large enough to provide sufficient accuracy for results that can be generalized to the entire population. The sample size program is based upon a common method used by statisticians to determine a sample size, yet is easy enough for anyone to use. (Please note: The confidence interval calculation procedure below applies only to percentage estimates and not to means.)

Sample Size Calculator

Population Size

Confidence Level

Response Rate

Population Proportion

Sample Size

Margin of Error

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Instructions for Using the Sample Size Calculator

Sample Size Calculator

Population Size: The exact number of people in the population that you are studying and from which the sample will be drawn.

Margin of Error: Indicates the desired degree of precision attached to an estimate computed from the survey. It indicates the range into which the estimate would fall if the entire population was surveyed. For example, if a 5 percent margin of error is acceptable to the researcher and the survey estimate of the measured characteristic is 48 percent, then if the entire population were surveyed, one would expect the true value of the characteristic of interest to lie between 43 percent and 53 percent.

Confidence Level: An indicator of how often the true percentage of the population would pick an answer lying within the confidence interval. For example, 95 percent confidence level means you can be 95 percent certain. Most researchers use the 95 percent confidence level.

Estimated Response Rate: This is an estimate of the percent of the sample that will complete the survey and is usually based on previous experience. For example, 95 percent response rate assumes that 5 percent of the people in the sample will not complete the survey because they refused or couldn’t be located for other reasons.

Population Proportion: This is an estimate of the percentage of your sample that will pick a particular response. For example, based on previous experience 40 percent will respond “Yes” and 60 percent will answer “No” to the question. It is best to assume the worst case percentage (50 percent) when determining a sample size.

Table 6-1 illustrates the increase in the variability of the estimates as the population proportion estimate approaches 50 percent. For example, for a sample of size 1,000, for a target characteristic of around 10 percent, the confidence interval (CI) would be the estimate 2.12 percent. For a sample of size 1,000, for a target characteristic of 50 percent, the CI would be the estimate 3.53 percent.

Sample Size: This is the number of people out of the entire population of interest that will be selected for the administration of the survey. It is NOT the number of completed surveys to be gathered. Depending on the response rate selected, the sample size estimate includes the number of completed surveys and a percentage of refusals or no contacts.

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Table 6-1. Half-widths of 95 percent confidence intervals (or margins of error) by various sample sizes and estimates of target characteristics (computed for a two-stage design with a design effect of 1.30)

Sample size

Estimates of Target Characteristics10

percent20

percent30

percent40

percent50

percent1,000 2.12 2.83 3.24 3.46 3.53

750 2.45 3.26 3.74 4.00 4.08

500 3.00 4.00 4.58 4.90 5.00

400 3.35 4.47 5.12 5.47 5.59

300 3.87 5.16 5.91 6.32 6.45

250 4.24 5.65 6.48 6.92 7.07

200 4.74 6.32 7.24 7.74 7.90

100 6.70 8.94 10.24 10.95 11.17

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7. Administer the Survey

At this point, the agency has completed all the steps necessary to administer the survey:

•

•

•

•

•

Identifiedwhichprogramorservicestoassess;

Selectedtheappropriatesurveyinstrument;

Determinedthebestmethodtocollectdata;

Selectedaservicerecipientsample;and

Developedaworkplanandbudget.

Thefollowingsectionsprovideastep-by-stepguidetoadministeringthesurveyinstrumentbytelephoneormail.

The Telephone Survey

Pilot the Data Collection ProceduresThePOMPSurveyInstrumentsandprocedureshaveundergonereliabilityandvaliditytestingandhavebeensuccessfullyadministeredoverthepasttenyears.AnAgency,however,maywanttoconducta pilot (i.e. administer the survey in the proposed manner to a small numberofrecipients)torefineitsdatacollectionprocedures.

Notify the Involved Agencies and the Sampled Service RecipientsThe agency sponsoring the survey sends correspondence to organizationssuchasAAAsorprovidersthathavedirectcontactwithservicerecipientswhoaresampledforthesurvey.Thecorrespondenceintroduces the survey and its purpose, explains the survey process, and includes the study timeline. The correspondence ensures that agencies areawareofthesurveyandareabletoanswerquestionsfromsampledservicerecipients.Afterthecorrespondenceisdistributed,theagencysponsoringthesurveymaywanttoscheduleaconferencecallwithagenciestoansweranyquestions.

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Notify the Service RecipientsTheagencysendsadvancenotificationcorrespondencetoinformservicerecipientsofthesurveytoreducethelikelihoodthattheywillthink thatit’satelemarketingcall.Thecorrespondenceincludesadescriptionofthepurposeofthesurvey,therequirementsofparticipation,notificationthatparticipationisvoluntary,andcontactinformationforobtainingadditionalinformationaboutthesurvey.Includeastatementthatparticipationinthesurveywillnotaffectservicesinanyway.Thecorrespondenceshouldbedistributed3-5dayspriortodatacollection.

(SeeAppendixBfortheCatawbaCouncilonAgingSampleLetterofInvitation.)

Select InterviewersTheagencyselectsinterviewerswhoarenotagencyemployees.Agencystaffmembersmaybiastheresultsofthesurveybyinhibitingtheservicerecipients’responses.Ifitisimpossibletouseoutsideinterviewers,theagencyshouldselectstaffmemberswhodonotworkdirectlywithservicerecipients.Thecharacteristicsofgoodinterviewersarelistedbelow:

•

•

•

Goodinterpersonalskills–Aninterviewerneedstohaveaclearandreasonablyloudspeakingvoicewithgoodprojection.Thisisveryimportantwheninterviewingolderpersonswhomayhavesomehearingloss.Interviewersmayneedtospeakslowlytoolderpeople.However,itisimportanttoshowsensitivitytotheservicerecipients and tailor the approach to the individual.

Apositiveattitudetowardaging–Interviewersshouldhaveapositiveattitudetowardaging.Interviewersshouldshowrespectandsensitivitytotheservice recipients. They need to refer to the service recipientsbytheirlastnamesunlessinvitedtousetheirfirstnames.

Dependability–Interviewersoftenworkwithoutsupervision,soitisimportanttohirepeoplewhoaredependable.Interviewerswilloftenconductinterviewsineveningsandonweekends,especiallywheninterviewingcaregiverswhomayworkduringregularofficehours.Thisoftenmeansthatinterviewersworkafterregularofficehoursandhaveirregularschedules.

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Interviewer TrainingThetopicstoincludeininterviewertraininginclude:

1.thebackgroundandpurposeofthesurvey,

2. survey ethics,

3.surveymaterialsandprocedures,and

4.generalofficeprocedures.

Animportantpartofinterviewertrainingisprovidingopportunitiestopracticeadministeringthesurveyandtheresponsestofrequentlyaskedquestions.

Background and Purpose of the SurveyAtthebeginningofthetraining,thetrainerexplainsthebackgroundandpurposeofthestudy;includingthesponsoringagency,thereasonfor the study, the potential uses of the results, and the timeline.

EthicsConfidentiality. Collecting data from service recipients to assess programsorservicesinvolveshumansubjects.Therefore,datacollectionissubjecttoanumberoflegalandethicalrequirements.Theagencyshouldinstructinterviewerstoprotectthenames,telephonenumbers,andotherpersonalinformationofthepeopletheyarecalling.Thisisespeciallytrueifinterviewerscallfromlocationsotherthananagency’sofficebuildingbecauseidentifyinginformationmaybedisseminatedviaemailattachments(mostlikelywithencryptionandpasswordprotections)ortransported—onpaperformsorbyelectronicdevicessuchaslaptopsordatastoragedevices—incarsoronpublictransit.Agenciestypicallyrequireinterviewerstosignaconfidentialityagreement.

(SeeAppendixBforaconfidentialityagreement.)

Theagencymustadoptspecialprocedurestoprotecttheconfidentialityofdataintransportorsentviaemail.Iftheagencyhasaconfidentialityform that employees must sign, include it in the discussion of agency policies. Protect information from unauthorized disclosure and use. Thisincludesinformationthatisstoredoutsideoflockedfilecabinetsandlockedrooms(i.e.,datathataretransportedbylaptop,CD,DVD,

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ormemorystick).Endthediscussionofconfidentialitybyaskingeachinterviewertosigntheagency’sconfidentialityform.Theexceptiontoconfidentialityisthedisclosureofelderabuse/neglectortheintenttoharmselforothers.Interviewersshouldinformrespondentsbeforehandthattheyarerequiredtoreportabuseorneglect to the appropriate parties. The agency needs to have a plan inplaceforinterviewerstofollowintheeventthatthishappens.

(SeeAppendixBforasampleconfidentialityform.)

Traininterviewerstoassureservicerecipientsthattheirresponsesareconfidentialandwillinnowayaffecttheirservices.Thissets the stage for service recipients to feel free to give honest responses. Ifinterviewersareemployedbytheagencythatprovidesservices,servicerecipientsmayworrythattheirresponsesarenotconfidentialandmayfeellessinclinedtohonestlyrespondtoitemsaboutconsumerassessmentofservices.Servicerecipientsmay also hesitate to give an honest response for fear of “hurting the feelings”ofserviceprovidersorfearthattheywillgettheserviceproviderintrouble.

Respondents’righttorefusal.Itisimportantforinterviewerstounderstandthatrespondentsmayskipanyquestionforanyreason.Interviewersareprovidedwithascripttoreadtorespondentsbeforeadministeringthesurveythatinformsthemofthisright.Iftheagencyisundertheauthorityofahumansubjectsinstitutionalreviewboard(IRB),thisdisclaimerlikelywillbemandatory.Interviewersshouldencouragepeopletoparticipate,butneverputany type of pressure on them to do so.

Respondentsrequiringservices.Sometimes respondents may reveal the need for additional services. When this happens, instruct interviewersonhowtohandlethisinformation.

Interviewerbias.Traininterviewerstoavoidintroducingbias.Interviewersmayintroducebiasbyshowingempathyorachangeintoneofvoice.Interviewersareadvisednottointerviewpersonstheyalreadyknow.Itisimportantthattheinterviewersunderstandthattheycannotinterpretaquestionfortheservicerecipientbecausedoingsowillintroducebias.

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Training AgendaThemajorityoftheinterviewertrainingcoversthecontentofthesurvey,proceduresforconductingthesurvey,andrecordkeeping.

Thesurveyinstrument. The training is a good opportunity tocarefullyreviewthesurveyinstrument.Thisensuresthatinterviewersarefamiliarwiththesurveyitemsandthattheirquestionsareanswered.

Introductoryscript.Theintroductoryscriptestablishescontactwiththeservicerecipientandensuresthathe/sheunderstandstheinformedconsentinformationinthecoverletter.Aswiththesurveyitems,interviewersarerequiredtoreadtheintroductoryscriptverbatim.

(SeeAppendixBforaScriptonEstablishingContact.)

Answeringmachine/voicemailprotocol. When attempting to reachtherespondent,theinterviewermayencountervoicemail.Sinceitisnotknownwhethertherespondentistheonlypersonwithaccesstothevoicemail,instructinterviewerstoavoidleavingany personal service recipient information, including the fact thathe/shereceivesservices.Usinganagreed-uponvoicemailprotocolensuresthattheinterviewersdonotrevealanyidentifyinginformation.

(SeeAppendixBforaScriptforInterviewerstoUseforAnsweringMachinesorVoiceMail.)

Recordingandsurveytrackingmaterials.Instructinterviewersonhowtotrackthenumberofrespondentscontactedandtheoutcomesofthecontacts.Therearemanyoptionstotrackthisinformation.Oneoptionistomaintainamasterlogbookwithalloftherespondentcontactinformationtorecordallthestatuses.Eachinterviewerisprovidedwith“callsheets”copiedfromthemasterlogbookthatcontaintherespondents’namesandcontactinformation.

(SeeAppendixBforaCaregiverSampleListandResults/Telephone

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InterviewerCallerLog.)

Another option is to issue individual respondent information sheets pairedwithanotebookforkeepingtrackofwhichinterviewerhastheinformationsheetforeachrespondent,timeofcheckoutandreturn of the information sheet, and disposition of the attempts to contact the respondents. The advantage of this option is that the informationsheetsareeasilytransferredfromoneinterviewer to another.

(SeeAppendixBforaPOMPSurveyContactSheet.)

Regardlessofwhichoptionisselected,interviewersmustmaintaina log to record each attempt to reach a respondent, including the date and the disposition of the contact. A general guideline is for interviewerstoattempttocontactrespondentsatleastfivetimes.Whenrespondentsaredifficulttoreach,instructinterviewerstovary the times of the call attempts. The service recipient may have astandingappointmentoractivitythattakeshim/herfromhome.Schedule calls from 9:00 a.m. to 8:00 p.m.

Surveyinstructions.Interviewertraineeshavedifferentlearningstyles. While the most important lessons are taught and practiced intraining,providewritteninstructions.Whenaquestionarises,itishelpfultoreferinterviewerstothewritteninstructionsoninterviewingtechniques.

(SeeAppendixBfortheSampleInstructionsforPOMPSurveyInterviewers.)

Practiceadministeringthesurvey. At the end of the training, interviewersareprovidedwithanopportunitytopracticethesurveyadministrationprocedures(introductoryscriptandinterview).Thetrainershouldpairinterviewerswithaseniormemberofthesurveyteamwhoisfamiliarwiththesurveyinstrumentandprocedures.Practicingwithaseniormemberofthesurveyteamprovidesanopportunitytoreinforcegoodskillsandcorrectanymistakesinahelpfulandsupportivemanner.Anotheroptionistoletinterviewerspracticeinterviewingeachotherandlistenforstrengthsandweaknesses.Givefeedbackindividuallyanddiscussanycommonmistakeswiththeentiregroup.Astandardpracticeistomonitorthefirstfewcallsmadebyeachinterviewertoidentifyadditionaltraining needs.

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The Mail SurveyTheinitialmailingincludesthefollowingcomponents:anenvelopeaddressedtotherecipient,acoverletter,thesurveywithacoversheet and instructions, and an agency’s self-addressed, stamped return envelope. After the initial mailing, send nonrespondents a remindercardandasecondmailingofthesurveyinstrument.Iftheagency’sresponserateisstillinadequateaftersendingthereminderpostcard and the second mailing, the agency might consider calling nonrespondentstoaskthemiftheyarewillingtocompletethesurveyoverthetelephone.Thefollowingparagraphsdiscussthisapproach more thoroughly.

Mailingenvelope. The size of the mailing envelope should accommodate all materials and include the agency’s return address preprintedontheenvelopeoronalabelintheupperleft-handcorner.Includeanyspecialinstructionstothepostofficeregardingspecialservicesrequiredsuchasachangeofaddressorreturnrequests.Therecipientaddresslabelmustbeproperlyplacedforpostalscanningandsufficientpostagemustbeprinted,stamped,oraffixedtotheenvelope.

Coverletter.Similartotheadvancenotificationletter,thecoverletter explains the purpose and importance of the survey and encouragesparticipation.Inaddition,thecoverletterexplainshowthe agency plans to use the results. Print the cover letter on agency letterheadandincludetheagencydirector’ssignature.Includea“pleasereturnby”date.Aduedate10-14daysfromthedayofthemailingprovidesservicerecipientssufficienttimetorespond.Includeatelephonenumbertocallifthereareanyquestionsandthanktheservicerecipientinadvanceforhis/herparticipation.

(SeeAppendixBfortheNewYorkStateOfficeonAgingcoverletter.)

Processingsurveyreturns.Developaprotocolforprocessingcompleted survey instruments. Adhering to the protocol ensures that survey instruments are not misplaced and that each service recipient returns only one completed survey instrument. Some of the completed survey instruments may arrive later than the deadlinestatedonthecoverletter.Establishasetofrulesregardingwhatconstitutestheclosingdateforacceptingreturnedsurveys.Forexample,willtheclosingdatebetheactualcalendardate,thepostmarkeddate,orsomespecifiednumberofdaysaftertheactualcalendar date?

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Surveyinstrumentwithinstructions.Includeacoverpagewithinstructionsonhowtocompletethesurvey.Proxyrespondentinstructionsforpeopleauthorizedtorespondonbehalfofservicerecipients are also included on the cover page. The survey instrument itself has instructions for responding to each item or set of items.

Stampedself-addressedenvelope.Includeastamped,pre-addressedenvelopewithsufficientpostagefortheservicerecipient to return the completed survey instrument.

Reminderpostcard.Thereminderpostcardshouldbemailedtononrespondentsapproximately1weekaftertheinitialmailing.Thereminderpostcardmayhelpincreasetheresponserate.Itremindsservicerecipientsofthesurveyandprovidesthemwithacontactnumberiftheoriginalsurveyinstrumentdidnotarrive.

(SeeAppendixBforaReminder/ThankYouPostcard.)

Follow-upletterwithsurveyinstrument.Mailafollow-upletterwiththe survey instrument to nonrespondents after the completion deadline. Itisimportanttoincludeasecondcopyofthesurveyinstrumentforthosewhomayhavethrownoutormisplacedtheoriginalsurvey.Dependingontheresponserate,anagencymayconsidersendingadditionalroundsofthefollow-upletterwiththesurveyinstrumenttoencourage participation.

(SeeAppendixBforaNewYorkStateOfficeonAgingreminderletter.)

Follow-uptelephonecall.Afollow-uptelephonecallcanbemadeto nonrespondents to give them the option of completing the survey overthetelephone.Providingservicerecipientswithanotherwaytoparticipate in the agency’s survey may increase the response rate.

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Mailing Surveys

step 1

Prepare materials: cover letter, copies of survey instruments and envelopes

step 2

Mail survey

step 3

Enter data into an electronic data entry utility as survey instruments are returned

step 4


step 5


step 6


step 7


step 8


8-1

8. Enter, Review and Analyze the Data

The purpose of converting responses from the survey to data files is to compile the responses in a single place for use during analysis. However, regardless of the survey method:

•

•

•

•

•

record responses in an electronic database,

check the accuracy of recorded responses and records (data),

reduce responses to manageable units for analysis,

analyze and interpret the data, and

address data storage and security.

While generally conducted sequentially, these steps will likely overlap if the survey is administered over a period of time.

Recording and Coding Responses into the Data Entry UtilitiesThe POMP website contains a data entry utility for each of the five service-specific survey instruments, with the databases for the cross-cutting modules embedded in each of the service-specific utilities. The database utilities are posted on the POMP website and are easily downloaded.

After administering the survey, the responses from each question are entered into the customized data entry utilities for each survey instrument. The data entry utilities have drop down menus for the user to enter the responses to the close-ended questions. There are fields in the database to enter verbatim responses to the open-ended questions.

Once all of the responses are entered into the data entry utility, the responses from each open-ended question are collated. This provides an opportunity for the data analyst to review the responses and to identify codes. The codes are textual or numerical representations of themes. For instance, there is an open-ended question on the caregiver survey instrument that asks how the service has helped the caregiver. When all of the survey instruments have been entered into the database, and all of the responses to the open-ended question have been collated, the analyst then examines the responses to the question for themes. After a theme is identified, it is given a specific code. Use of the new code gives the analyst an opportunity to identify groups of responses that reflect a particular theme.1

1 A good guide to quantitative analysis is Miles, M, & Huberman, A.M. (1994). Qualitative Analysis: An Expanded Sourcebook, Thousand Oaks, CA: Sage Publications.

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Check Data AccuracyBefore analyzing and interpreting the data, ensure the accuracy of the data entered. First make sure that the respondents answered each question properly and that responses in the database are correct.

1. Check all responses from all returned survey instruments.

2. Confirm that the number of respondent records in the data set is the same as the number of returned surveys to ensure that no data were omitted or duplicated.

3. Check the accuracy of all numeric codes for each variable name in the data file. For example, if only codes 1-4 are applicable for question 1, ensure that a code of 6 is not inadvertently entered into the data file.

4. A basic frequency run for each variable name will reveal data entry errors by showing whether the values are within the parameters.

Analyze Data and Interpret Results

Data AnalysisOnce the responses are converted into a data file and checked for accuracy, analysis of the data can begin. Some basic statistical measures to consider for analysis include measures of central tendency, frequencies and percentages, and cross-tabulations. As an introduction, it is good to summarize key demographic characteristics of the respondents to give readers an understanding of who completed the survey. For example, include the mean and range of the age of respondents, the percentage of males and females, and different races.

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Measures of Central Tendency Measures of central tendency give an indication of where the center of the response distribution is located. The most common measure of central tendency is the mean (or average). Another measure of central tendency is the median. The median is the middle value when data are arranged from the lowest value to the highest value. Last, the mode is the value that appears most frequently in the data set. For example, suppose you asked five service recipients their age, and these were their responses:

68, 72, 75, 82, 82.

Based on these responses, the mean is 75.8, the median is 75, and the mode is 82.

Frequencies and PercentagesFrequencies and percentages are useful statistics to analyze the responses to items that ask service recipients to rate programs and services. These statistics will tell how many and what percentage of people responded with each answer. For example, if a person conducted a survey of congregate meals, calculate the number and percentage of service recipients who rated the program excellent, very good, good, fair, and poor. For simplicity, group certain responses together. In the above example, rather than report on the five possible answers, provide statistics on the number and percentage who rated the service excellent, very good, and good and the percentage who rated the service fair and poor.

Cross-Tabulations Analyze two or more variables simultaneously by running cross-tabulations. Cross-tabulations allow a comparison of the responses of different groups of service recipients. For example, do men and women rate the services similarly? With a cross-tabulation table, an analyst can see the distribution of respondents’ ratings by sex. If the sample size is sufficient, the analyst may opt to conduct statistical tests to ascertain if differences did not occur by chance alone.

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Data Storage and SecuritySurvey staff need to ensure that the completed survey instruments and electronic data files are properly stored to protect the confidentiality of service recipients. A data storage and security protocol is determined before obtaining IRB approval to conduct the survey. The protocol includes clear instructions on where to store the completed survey instruments and data files and who can have access to this information. Any additional security measures must be detailed in the protocol, including the use of locked file cabinets to store completed survey instruments and password-protected data files, to ensure that only those with permission can access confidential information. The data storage and security protocol includes guidelines on the use of portable devices such as laptop computers and flash drives.

In addition, check with the legal department or other appropriate department regarding how long data files and paper questionnaires must be kept. Public document retention laws differ by state, but five to seven years is a general “rule of thumb.” If the completed survey documents have been scanned, shred the paper version because the scanned documents are generally considered the “legal entity.”

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9. Prepare the Report and Disseminate the Results

Writing and disseminating survey results allow an agency to share findings with others in a meaningful way. Sharing the results can help increase program effectiveness, advocate for additional funding, and publicize programs.

The first step in writing the report of survey results is to consider the audience. Who would be interested in the results? Results can be shared with program staff, board members, community members, agency or funding administrators, and policy and decision makers.

Writing the Report The purpose of the report is to summarize and interpret the findings, provide conclusions, and make recommendations for program changes and enhancements as needed.

Make reports informative and easy to understand. Keep the language simple and avoid using technical language or jargon. Presenting findings in different ways through visual displays, quotes, and narrative comments will make the report interesting to read. Visual displays such as graphs and tables can highlight information in a concise and interesting manner. Choose the type of graph (e.g., bar, pie, line) that best conveys the results.

(See Appendix B for Ohio Department of Aging, Analysis of Surveys: Senior Farmers Market Nutrition Program.)

To help stakeholders locate key information quickly, the report should contain several components. A sample report outline that describes the purpose of each section is on the next page.

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Sample Report Outline I. Executive Summary—Provide a short summary of the

report.

II. Background—Include information about the programs and services being studied and the local agency or agencies involved.

III. Purpose—Explain the purpose of the survey and the report.

IV. Methodology—Describe the process of sampling, data collection and data analysis. Include the response rate, etc.

V. Findings—Detail the findings from the survey(s) conducted. Include charts and graphs to highlight key points.

VI. Conclusions—Summarize the findings and draw conclusions.

VII. Recommendations—List recommendations for program improvement, as appropriate.

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Creating Other Documents There is more than one way to share survey findings. Agencies can create documents that present survey findings for diverse stakeholders. For example, funding authorities may prefer a report that details the survey process and results, while people receiving services may favor an informal overview of the key findings. Below are other types of documents to consider when disseminating survey results.

1. Newsletters. Short, non-technical articles that summarize the key findings and the “bottom line” message from the survey.

(See Appendix B for North Carolina’s Pass it On Newsletter.)

2. Handouts and Fact Sheets. A one-page handout or fact sheet that conveys key information gleaned from the survey is another effective method to share findings. Brief handouts allow an agency to present findings in a concise and easy to understand manner. For example, a transportation fact sheet from POMP survey data introduces information funded by the OAA to a human services transportation council. The same handout was used at a public listening session discussing transportation issues for older adults.

(See Appendix B for the Report to NCDOT Public Transportation Division’s Human Services Transportation Council.)

3. Annual Reports. Many AAAs and service providers produce an annual report for current and potential funders. Annual reports typically include data on the agency’s outputs, such as number of meals delivered or number of older adults receiving in-home aide services.

(See Appendix B for the Amber River Area Agency on Aging Annual Report.)

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4. Service Provider In-House Memos. If an agency’s survey includes a large enough sample from specific subpopulations, it will allow comparisons among subpopulations (e.g. counties, providers). The agency will want to use these for discussing quality issues.

(See Appendix B for a sample Memo to In-Home Aide Providers – this is an example of a memo from an AAA director to county agencies within her region. The director uses findings from the survey to raise questions prior to a meeting with providers to discuss quality issues. Notice that the findings are used as a launching point for discussion.)

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Disseminating the Findings Consider the target audience when disseminating findings and choose a mix of dissemination methods to reach different audiences. The suggestions below are by no means exhaustive. Agency staff may have other ideas for sharing the survey findings.

1. Presentations. Use presentations to share findings at office meetings, agency or regional sessions, public gatherings, or at professional association meetings. PowerPoint slides are an effective tool to present findings. PowerPoint presentations are most effective when they highlight key points of the survey findings. However, observe the adage “less is more.” If too much information is placed in the presentation, the audience may be focused on reading the slides rather than listening to the speaker.

2. Handouts or fact sheets. These can be used to supplement a PowerPoint presentation or can be used independently. One benefit of handouts is that users can easily reference the information. The type of presentation delivered and the resources incorporated depend on the audience.

3. Web Posting. Post reports, newsletters, or PowerPoint slides on the agency’s website. If posting documents on the Internet, ensure that documents meet the agency’s information technology (IT) requirements (e.g. Section 508-compliance). Also, consider posting documents in several electronic formats (PDF, Word, etc.) to ensure accessibility for all those interested in the agency’s findings. Notify stakeholders that survey findings are available on the agency’s website.

4. Mail/Email. Mail or email are direct methods of data distribution. If mailing the report or other documents to stakeholders, make sure that funds are budgeted for supplies and mailing costs. If emailing, ensure accurate contact information (e.g., addresses, email addresses) for all those on the agency’s distribution list.

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10. Compare the Results to Other National Surveys

Using several illustrative sources, this chapter identifies data sets and methods for comparing an agency’s performance results with those found in national surveys and other benchmarks. Interpreting the findings from your performance measurement surveys can occur in several ways, including tracking changes among the same service recipients over time (longitudinal or panel studies), observing changes in response patterns across multiple cross-sectional service recipient surveys, and comparing your results to those from national surveys. This chapter also provides links to many sources of national survey data on aging for comparative purposes. Several of these sources include national surveys that use the same measures as the Performance Outcome Measurement Project (POMP) and, therefore, provide opportunities for direct comparison.

As a caveat, it is important to ensure that the national data you select for comparison purposes comes from geographic areas that are similar to yours. For example, if your agency serves exclusively a rural service recipientele, then you will want to sub-set the national data for non-metropolitan areas. The AoA National Survey, for example, can be sub-setted according to urban or rural locations, as well as other stratifies that allow comparisons (see following paragraph).

Comparing Consumer-Reported Quality and Outcomes Using the AoA National Surveys of Older Americans Act ParticipantsMany of the measures in this Toolkit are also part of the AoA National Surveys of OAA Participants. This provides state or local agencies an opportunity to compare their service recipients’ assessments of service quality and outcomes with national figures. For example, both the AoA National Survey and the Tookit’s home-delivered meals survey instruments ask respondents to rate the quality of home-delivered meals, using a five-point scale from “Excellent” to “Poor.” The AoA survey responses are available at www.agidnet.org/

www.agidnet.org/

10-2

Comparing Demographic Characteristics and FunctioningSeveral national data sets are available for comparing the characteristics of service recipients to nationally representative samples. These characteristics include:

•

•

•

characteristics (e.g., age and income);

physical functioning (e.g., activities of daily living [ADL] and instrumental activities of daily living [IADL] limitations) and;

social functioning (e.g., adequacy of social activities).

The AoA National SurveysThe National Surveys use the same physical functioning battery of questions as POMP, which provides another basis for comparison with an agency’s data. The survey results are available on AoA’s data website (www.agidnet.org) that links visitors to all the previous AoA National Surveys results via a user-friendly query system. Click on “Data Files,” National Survey of OAA Participants, the survey year, and service of interest. Next, select the ADL or IADL option as a “stratifier” variable. This query system gives the agency two categories of ADL or IADL limitations: 0-2 and 3+.

The National Surveys also show income information for each of several services, as another basis for comparison. It is likely that an agency’s ADL, IADL, and income percentages will be similar to the National Surveys results, which are averages across a representative sample of agencies and service recipients for each of several services. If there are significant differences, it may make sense to explore why this is occurring. For example, there may be one among several providers of a service that is causing another agency’s average ADL/IADL limitation or low-income figures to be higher or lower than the national average. This could mean that this provider is targeting services to frail service recipients to a greater or lesser degree than is the case for others providing this service. It is important to keep in mind that such differences may have logical explanations and are not necessarily indicative of high versus low performance. These variations from the norm simply provide a focus for monitoring activities.

www.agidnet.org

10-3

The National Health Interview Survey, Supplement on AgingThe National Health Interview Survey, Supplement on Aging, which was last conducted in 1994/95, provides another basis for comparison. Figures from this survey pertain to the 70+ household population and can provide a basis for comparison with an agency’s service recipient responses to these same questions. Social functioning is an important quality-of-life measure and a major indicator of well-being among the elderly. In addition to promoting physical functioning, in terms of ADL and IADL activities, Older Americans Act services have a goal of reducing social isolation. For example, among the U.S. household population age 70+, 24.3 percent reported that they would like to be doing more social activities, compared to 46.3 percent for home-delivered meals service recipients, showing considerable targeting of services to those who are socially isolated (see Table 10-1).

Table 10-1. Social Well-Being Among Persons Age 70+: Comparing OAA Home-Delivered Meals Service recipients and the U.S. Household Population

Present Social Activities

OAA Service

recipients* (percent)

U.S. Population**

(percent)

About enough 51.7 73.1

Too much 2.0 2.6

Would like to do more 46.3 24.3

*Original tabulations from the 2005 AoA National Survey of OAA Participants

** Original tabulations from the 1994/95 Supplement on Aging to the National Health Interview Survey

10-4

The Survey of Income and Program Participation (SIPP), Disability Topical Module The U.S. Census Bureau (Census Bureau) periodically conducts the SIPP Survey, which is an excellent source of information about the characteristics of persons living in the community, including the elderly. The POMP physical functioning questions came from the SIPP Disability Topical Module, which means the SIPP provides a good basis for comparison using an agency’s service recipient data. The most readily available SIPP disability data come from Census Bureau published reports. The most recent report, Americans with Disabilities: 2005, was published in December 2008 and is available at http://www.census.gov/prod/2008pubs/p70-117.pdf.

In Table B-1 (pages 16-18) of the Americans with Disabilities report, there are frequencies and percents of elderly persons (65+) based on the individual ADL and IADL questions in the POMP survey, as well as a composite measure for one or more ADL limitations. (See copy of this table beginning on the following page) .The same information is available for IADL limitations. Consulting this table will allow an agency to compare between the ADLs and IADLs of its service recipients and the ADLs and IADLs of the elderly population as a whole. This can show, for example, how much more frail an agency’s service recipients are compared to the general elderly population. In particular, a service provider can compute the percentage of its service recipients (those age 65+) who have one or more ADL limitations versus the U.S. household population 65+ with this level of frailty using the Americans with Disabilities report.

As Table 2 illustrates, it is likely that the percentage for an agency’s service recipients with ADL or IADL limitations will be much higher than for the 65+ population, thereby demonstrating that the agency’s programs are targeting the frailest of elderly. When making these comparisons, be sure to use the same ADL or IADL items for an agency’s service recipientele that are in the SIPP Disability Topical Module. For example, the POMP IADL items include more activities than the SIPP (e.g., the ability to use available transportation) to be

http://www.census.gov/prod/2008pubs/p70-117.pdf

10-5

consistent with AoA’s State Program Report categories. To illustrate how to compare the data between an agency and the SIPP Survey, see Table 10-2 below, which uses the 2005 AoA National Surveys service recipients in lieu of the agency’s own data (see the description of the National Surveys below). For example, this table shows that OAA home-delivered meals service recipients 65+ are six times more likely to have at least one ADL limitation than the U.S. household population 65+ (75 percent versus 12.5 percent), documenting a high level of targeting of OAA programs to a frail elderly constituency. This table also compares several other characteristics as described below.

Table 10-2. Percent of Persons Age 65+ with Selected Characteristics: Older Americans Act Home-delivered Meals Service recipients, Compared to the U.S. Household Population, 2005

Selected Characteristics

OAA Service recipients* (percent)

U.S. Population**

(percent)

1+ ADL Limitations 75.0 12.5

Household Income < $10,000 39.8 4.7

Less Than a High School Education 41.6 16.8

*Original tabulations from the 2005 AoA National Survey of OAA Participants

** http://www.census.gov/prod/2008pubs/p70-117.pdf

http://www.census.gov/prod/2008pubs/p70-117.pdf

10-6

The SIPP also collects data on income and poverty among older persons. Table B-2 (page 19) of the Americans with Disabilities report presents household incomes in $1,000 increments through $10,000 and above, as well as the number below the poverty level, all of which appear by level of disability (for persons 65+). This shows the strong correlation between disability (as an indicator of need for services) and poverty, which is likely apparent among home care service recipients in state and community programs on aging. The income and poverty figures in this table are percents for each of three levels of disability. In order to construct a total count and percent of persons 65+ by these income categories and the poverty threshold, multiply the percents by their corresponding total person counts at the top of the table. Summing the results will allow one to compute total income and poverty levels for persons 65+, regardless of level of disability. It is important to note that poverty levels among older persons in general are quite low (8.2 percent), but this is a small consolation to those frail older persons who need in-home supports and have few financial resources to pay for them. Table 10.2 shows that among OAA home-delivered meals service recipients age 65+, 39.8 percent have annual household incomes below $10,000, compared to just 4.7 percent for the U.S. household population 65+. This means that OAA service recipients are 8.5 times more likely to have incomes below $10,000 than the elderly population, overall, also demonstrating a high degree of targeting to low income persons.

Another demographic risk factor associated with service needs is a low level of formal education. Both the SIPP and the National Surveys collect this information, as Table 10.2 also shows. Among OAA home-delivered meals service recipients age 65+, 41.6 percent have less than a high school education (compared to just 16.8 percent of the U.S. household population 65+). This means that OAA service recipients are 2.5 times more likely to have less than a high school education than their counterparts in the general population, another indication of effective targeting.

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Appendix A: Mail and Telephone Surveys

Mail and Phone Survey Introduction & SummaryAppendix A contains both mail and telephone versions of each survey instrument and cross cutting module. The mail versions are self-administered. The mail version of the congregate meals survey instrument has the flexibility for administering at meal sites.

The mail and telephone survey instruments are posted on the POMP Website in PDF and Word formats. The Word format is provided for agencies that want to develop additional items or tailor existing ones to a particular location.

POMP Final: Caregiver Services Survey Instrument (Mail Version)

Office Use Only:

Client ID: ____________________________________________________________________ Service Enrollment Date: ________________________________________________________ Date of Survey Administration: ____________________________________________________

This survey is about the caregiver services that you receive. We are interested in the length of time you have received caregiver services and whether the caregiver services have been helpful. Your answers will help us make sure that the services meet your needs. Participation in the survey is voluntary and you may skip any question. Your answers will be kept confidential and will not influence the services that you receive.

CR1. Are you still caring for a person age 60 years or older?

Yes .................................................................................... 1 GO TO CR2 No ..................................................................................... 2

CR1a. What happened to change your caregiving situation? Check all that apply.

a. The person you care for died ................................... 1b. The person you care for was placed in a nursing

home .................................................................... 2

c. The person you care for was placed in an assisted living facility .......................................................... 3

d. The person you care for was placed in a family type group home (family care home) ............................... 4

e. The person you care for is getting help temporarily from a different caregiver ........................................ 5

f. The person you care for has a different permanent caregiving arrangement .......................................... 6

g. The person you care for got better and no longer needs help ............................................................. 7

h. The needs of the person you care for exceed your capacity to help ...................................................... 8

i. Your health status has declined ................................ 9

j. Your employment status has changed ....................... 10

k. Your family situation has changed ............................ 11

l. Other reason ......................................................... 91

Please describe: _____________________________

__________________________________________

END SURVEY

2

CR2. When was the last time you received caregiver support services?

Today or yesterday.................................................... 1

More than 1 day, but not more than a week ago ........... 2

More than 1 week, but not more than a month ago ....... 3

More than 1 month ago .............................................. 4

Over 1 year ago ........................................................ 5

Thank you, but the focus of this survey is on people who have used the service within the past year. Thank you for your time.

CR3. How long have you been receiving caregiver services?

6 months or less ................................................................. 1

More than 6 months, but less than 1 year .............................. 2

At least 1 year, but less than 2 years ..................................... 3

2 to 5 years ........................................................................ 4

More than 5 years ............................................................... 5

CR4. What is your relationship to the person you care for? Are you his or her ...

Husband ............................................................................ 1

Wife .................................................................................. 2

Domestic partner ................................................................ 3

Father ................................................................................ 4

Mother ............................................................................... 5

Grandfather ........................................................................ 6

Grandmother ...................................................................... 7

Brother .............................................................................. 8

Sister ................................................................................ 9

Uncle ................................................................................. 10

Aunt .................................................................................. 11

Son ................................................................................... 12

Son-in-Law ......................................................................... 13

Daughter............................................................................ 14

Daughter-in-Law ................................................................. 15

Other relative (not mentioned above) .................................... 16

Friend or neighbor or another person ..................................... 17

CR5. Has someone from the agency helped you or given you information to connect you to the services and resources that you need as a caregiver?

Yes .................................................................................... 1

No ..................................................................................... 2

3

CR6. Have you received respite care, which allows you a brief break while temporary care is provided, either in your home or someplace else?

Yes .................................................................................... 1

No ..................................................................................... 2

CR7. Have you received caregiver training or education, including participation in support groups, to help you make decisions and solve problems in your role as a caregiver?

Yes .................................................................................... 1

No ..................................................................................... 2

CR8. Has the agency provided you with any supplemental services to help you provide care, such as home modifications, nutritional supplements such as Ensure or Boost, assistive devices such as canes or walkers, personal emergency response system, specialized equipment such as sleep apnea machines or hospital beds, stipends, etc.?

Yes .................................................................................... 1No ..................................................................................... 2

CR9. Of the caregiver services you received, which one service was the most helpful? Check only one.

Help or information connecting you to services and resources ......................................................................... 1

Respite Care Services .......................................................... 2

Caregiver Training or Education, including Counseling or a Support Group, or ............................................................. 3

Other Supplemental Support Services or Assistance ................ 4

Specify: __________________________________________

CR10. As a result of the caregiver services, do you…

Yes No

a. Have more time for personal activities ..................... 1 2

b. Feel less stress ..................................................... 1 2

c. Have a clearer understanding of how to get the services you and the person you care for need .... 1 2

d. Know more about the condition or illness of the person you care for ............................................... 1 2

e. Feel more confident in providing care to the person you care for ......................................................... 1 2

4

CR11. Would the person you care for have been able to continue to live in the same home if caregiver services had not been provided?

Yes .................................................................................... 1 GO TO CR12 No ..................................................................................... 2 GO TO CR11a

CR11a. Where would the person you care for be living? Check only one answer.

In your (caregiver’s) home ........................................... 1

In the home of another family member or friend ............. 2

In an assisted living facility ........................................... 3

In a nursing home ....................................................... 4

The person you care for would have died ........................ 5

Other ......................................................................... 91

Describe: ____________________________________

CR12. Thinking about the caregiver services that you have received, how would you rate these services? Would you say…

Excellent ............................................................................ 1

Very good .......................................................................... 2

Good ................................................................................. 3

Fair ................................................................................... 4

Poor .................................................................................. 5

CR13. Would you recommend these services to a friend?

Yes .................................................................................... 1

No ..................................................................................... 2

CR14. Have the caregiver services enabled you to provide care for a longer period of time than would have been possible without these services?

Yes .................................................................................... 1No ..................................................................................... 2

CR15. In general, would you say that the caregiver service has helped you?

Yes .................................................................................... 1 GO TO CR15a No ..................................................................................... 2 GO TO CR16

5

CR15a. How has the caregiver service helped you?

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

CR16. Do you have any recommendations to improve the caregiver service?

Yes .................................................................................... 1 GO TO CR16a No ..................................................................................... 2

CR16a. What recommendations do you have for improving the service?

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

Thank you very much for your time and cooperation. Your answers are very important to us in improving the caregiver services.

6

Module A: Care Provided

In this section of the survey, we would like to obtain some basic information about how much care you provide for the person you care for.

CRA1. How long have you been caring for this person?

|___|___| Years |___|___| Months

CRA2. Thinking about all the family members or friends who provide help, care, or supervision for the person you care for, what proportion of the care do you provide during a typical week? Check only one.

Would you say…

Less than one-quarter .......................................................... 1About one-quarter ............................................................... 2About one-half .................................................................... 3About three-quarters ........................................................... 4All or almost all of the care ................................................... 5

CRA3. Does the person you care for live with you?

Yes .................................................................................... 1 GO TO CRA5 No ..................................................................................... 2

CRA4. Does the person you care for live alone?

Thank you. This concludes Module A.

Yes .................................................................................... 1

No ..................................................................................... 2

7

CRA5. In your judgment can the person you care for be left alone (meaning he/she does not require 24 hour help/supervision)? Check only one.

Yes, the person you care for can be left alone for extended periods with no concerns .................................................... 1

Thank you. This concludes this portion of the survey.

Yes, the person you care for can be left alone but needs to be checked on in person several times a day ........................ 2

Yes, the person you care for can be left alone, but only for short periods of time (2 hours or less) ................................. 3

No, the person you care for cannot be left alone and needs 24-hour supervision ........................................................... 4

CRA5a. Are you responsible for providing help or supervision to the person you care for on a 24-hour basis?

Yes .................................................................................... 1 Thank you. This concludes this portion of the survey.

No ..................................................................................... 2

CRA5b. Please tell me how you would rate the intensity level of the 24-hour care you currently provide:

1 = The care provided over a 24-hour period is not very intense.

5 = The care provided over a 24-hour period is very intense.

1 2 3 4 5 Least intensity Greatest intensity

Module B: Burdens and Rewards of Caregiving

The next group of questions ask about the rewards and burdens you may feel as a caregiver.

CRB1. The following questions ask about the positive aspects of caregiving and give you some choices for answers. Please choose the answer that best tells how you feel.

Always Usually Some-times Rarely Never

a. As a caregiver, how often do you feel that you are helping the person you care for continue to live at home............................. 1 2 3 4 5

b. How often does being a caregiver for the person you care for give you the joy of spending time with someone you care about ....................................................... 1 2 3 4 5

c. How often does being a caregiver provide you with a sense of accomplishment ............ 1 2 3 4 5

d. How often does providing care for the person you care for give you the satisfaction of knowing that they are receiving the care and attention they need ... 1 2 3 4 5

e. How often do you feel that the person you care for appreciates the care that you are providing for them..................................... 1 2 3 4 5

f. As a caregiver, how often do you feel you are fulfilling your duty by caring for the person you care for ................................... 1 2 3 4 5

8

9

CRB2. In your experience as a caregiver, what is the one most positive aspect of caregiving? Check only one.

Helping the person you care for live at home .......................... 1Spending time with someone you care about .......................... 2Feeling a sense of accomplishment ........................................ 3Satisfaction that care and attention are received ..................... 4Being appreciated, or ........................................................... 5Fulfilling a duty ................................................................... 6None ................................................................................. 7

CRB3. Now we would like to ask you about potential difficulties you may face in caring for the person you care for. Please respond to each of the following questions with one of the options provided. In your experience as a caregiver, how often do you feel that …


a. Caregiving creates a financial burden for you ......................................................... 1 2 3 4 5

b. Caregiving does not leave you enough time for yourself ............................................... 1 2 3 4 5

c. Caregiving does not leave enough time for your family ............................................... 1 2 3 4 5

d. Caregiving interferes with your work ........... 1 2 3 4 5

e. Caregiving negatively affects your health ..... 1 2 3 4 5

f. Caregiving conflicts with your social life ....... 1 2 3 4 5

g. Caregiving causes you stress ...................... 1 2 3 4 5

CRB4. What is the greatest difficulty you have faced in your caregiving? Check only one.

Would you say caregiving:

Creates a financial burden .................................................... 1

Doesn’t leave enough time for yourself .................................. 2

Doesn’t leave enough time for your family .............................. 3

Interferes with your work ..................................................... 4

Creates or aggravates problems with your health .................... 5

Conflicts with your social life ................................................. 6

Creates stress ..................................................................... 7

10

Module C: Impact on Employment

CRC1. Have you ever been employed?

Yes .................................................................................... 1No ..................................................................................... 2 Thank you.

This concludes Module C.

CRC2. What is your current employment status? Are you …

Working full time ................................................................. 1 GO TO CRC3 Working part time ............................................................... 2

Retired............................................................................... 3

Not working ........................................................................ 4

CRC2a. Did your caregiving responsibilities cause you to quit work or retire early?

Yes .................................................................................... 1

No ..................................................................................... 2 Thank you. This concludes Module C.

CRC3. Has providing care for the person you care for ever interfered with your employment?

Yes .................................................................................... 1

No ..................................................................................... 2 Thank you. This concludes Module C.

_________________________________________

11

CRC4. Because of providing care for the person you care for, have you ... Check all that apply.

Yes No

a. Taken a less demanding job ................................... 1 2

b. Changed from full-time to part-time work ................ 1 2

c. Reduced your official working hours ........................ 1 2

d. Lost some of your employment fringe benefits .......... 1 2

e. Had time conflicts between working and caregiving ... 1 2

f. Used your vacation time to provide care .................. 1 2

g. Taken a leave of absence to provide care ................. 1 2

h. Lost a promotion ................................................... 1 2

i. Worked less than your normal number of hours last month ........................................................... 1 2

j. Other .................................................................. 1 2

Describe: __________________________________

12

Module D: Health of Caregiver

CRD1. Do you have any kind of health problem, physical condition, or disability that affects the kind or amount of care that you can provide to the person you care for?

Yes .................................................................................... 1No ..................................................................................... 2 Thank you.

This concludes Module D.

CRD1a. What is that problem, condition, or disability? Check all that apply.

1. Back problems and other joint problems/Arthritis ............... 12. Heart problems/High Blood Pressure/Hypertension/Stroke .. 2

3. Diabetes ....................................................................... 3

4. Allergies/Asthma/Other breathing/Lung problems .............. 4

5. Mental health (anxiety, fear, depression, emotional problems) ....................................................... 5

6. Eye problems ................................................................. 6

7. Other ............................................................................ 91

Describe: _______________________________________

CRD2. Have your caregiving activities created or worsened any of these conditions, problems, or disabilities?

Yes .................................................................................... 1No ..................................................................................... 2

13

Module E: Demographics

We are interested in knowing more about the demographic characteristics of our clients. We would appreciate if you would answer a few questions about yourself. All this information will be kept confidential.

CRE1. What is your sex?

Male .................................................................................. 1Female .............................................................................. 2

CRE2. In what year were you born?

|___|___|___|___| Year

CRE3. What is your highest education level?

Less than high school diploma .............................................. 1High school diploma ............................................................ 2Some college, including associate degree ............................... 3Bachelor’s degree ................................................................ 4Some post-graduate work or advanced degree ....................... 5

CRE4. Are you Spanish, Hispanic, or Latino?

Yes .................................................................................... 1No ..................................................................................... 2

CRE5. What is your race? Check all that apply.

a. American Indian or Alaskan Native ................................... 1b. Asian ............................................................................ 2c. Black or African-American ............................................... 3d. White/Caucasian ............................................................ 4e. Native Hawaiian/Other Pacific Islander .............................. 5f. Other race ..................................................................... 6

Describe: _______________________________________

14

CRE6. What is your marital status?

Now married ....................................................................... 1 Widowed ............................................................................ 2 Divorced ............................................................................ 3 Separated .......................................................................... 4 Never married .................................................................... 5

CRE7. Where is your home located? Would you say…

In a city ............................................................................. 1 In a suburban area .............................................................. 2 In a rural area .................................................................... 3

CRE8. How many people live in your household, including yourself?

|___|___| Number of Household Members

CRE9. How many persons total are you caring for, not counting the person you care for?

|___|___| Number of Persons

CRE10. Thinking about the total combined income from all sources for all persons in this household, was your total household annual income during the past year above or below $20,000? (IF NEEDED: including income from jobs, Social Security, retirement income, public assistance, and all other sources)

Below $20,000 .................................................................... 1 → GO TO CRE11 Above $20,000 ................................................................... 2 → GO TO CRE12

CRE11. Which category best describes your total household annual income during the past year?

$10,000 or less ................................................................... 1 GO TO CRE13 $10,001 to $15,000 ............................................................. 2

$15,001 to $20,000 ............................................................. 3

15


$20,001 to $30,000 ............................................................. 1$30,001 to $40,000 ............................................................. 2$40,001 to $50,000 ............................................................. 3Over $50,000 ..................................................................... 4

CRE13. What is the sex of the person you care for?

Male .................................................................................. 1Female .............................................................................. 2

CRE14. What is the age of the person you care for?

|___|___|___| Years

16

Module F: Health and Physical Functioning of the Person You Care For

CRF1. Does the person you care for have difficulty getting around inside the home?

Yes .................................................................................... 1No ..................................................................................... 2 → GO TO CRF2

CRF1a. Does the person you care for need the help of another person to perform this activity?

Yes ............................................................................ 1

No ............................................................................. 2

CRF2. Does the person you care for have difficulty going outside the home, for example to shop or visit a doctor’s office?

Yes .................................................................................... 1

No ..................................................................................... 2 → GO TO CRF3


Yes ............................................................................ 1

No ............................................................................. 2

CRF3. Does the person you care for have difficulty getting in or out of bed or a chair?

Yes .................................................................................... 1

No ..................................................................................... 2 → GO TO CRF4


Yes ............................................................................ 1

No ............................................................................. 2

CRF4. Does the person you care for have difficulty when taking a bath or shower?

Yes .................................................................................... 1

No ..................................................................................... 2 → GO TO CRF5

17


Yes ............................................................................ 1

No ............................................................................. 2

CRF5. Does the person you care for have difficulty when dressing?

Yes .................................................................................... 1No ..................................................................................... 2 → GO TO CRF6


Yes ............................................................................ 1

No ............................................................................. 2

CRF6. Does the person you care for have difficulty when walking?

Yes .................................................................................... 1

No ..................................................................................... 2 → GO TO CRF7


Yes ............................................................................ 1

No ............................................................................. 2

CRF7. Does the person you care for have difficulty eating?

Yes .................................................................................... 1

No ..................................................................................... 2 → GO TO CRF8


Yes ............................................................................ 1No ............................................................................. 2

18

CRF8. Does the person you care for have difficulty using the toilet or getting to the toilet?

Yes .................................................................................... 1No ..................................................................................... 2 → GO TO CRF9


Yes ............................................................................ 1No ............................................................................. 2

CRF9. Does the person you care for have difficulty keeping track of money or bills?

Yes .................................................................................... 1

No ..................................................................................... 2 → GO TO CRF10


Yes ............................................................................ 1No ............................................................................. 2

CRF10. Does the person you care for have difficulty preparing meals?

Yes .................................................................................... 1

No ..................................................................................... 2 → GO TO CRF11


Yes ............................................................................ 1No ............................................................................. 2

CRF11. Does the person you care for have difficulty doing light housework, such as washing dishes or sweeping a floor?

Yes .................................................................................... 1No ..................................................................................... 2 → GO TO CRF12

19


Yes ............................................................................ 1No ............................................................................. 2

CRF12. Does the person you care for have difficulty doing heavy housework, such as scrubbing floors or washing windows?

Yes .................................................................................... 1

No ..................................................................................... 2 → GO TO CRF13


Yes ............................................................................ 1No ............................................................................. 2

CRF13. Does the person you care for have difficulty taking the right amount of prescribed medicine at the right time?

Yes .................................................................................... 1

No ..................................................................................... 2 → GO TO CRF14


Yes ............................................................................ 1

No ............................................................................. 2

CRF14. Does the person you care for have difficulty using the telephone?

Yes .................................................................................... 1No ..................................................................................... 2 → GO TO CRF15


Yes ............................................................................ 1

No ............................................................................. 2

20

CRF15. Does the person you care for have difficulty driving an automobile?

Yes ............................................................................ 1

No ............................................................................. 2

21

Module G: Service and Information Needs

The next two questions ask you to think about what additional services and information may be helpful to you as a caregiver.

CRG1. In addition to the kinds and amounts of services you are receiving, (and the services that the person you care for is receiving), what additional or new kinds of help would be valuable to you as a caregiver?

Yes No

a. Housekeeping assistance for the person you care for . 1 2

b. Shopping assistance for the person you care for ....... 1 2

c. Transportation assistance for the person you care for .. 1 2

d. Assistance in making meals for the person you care for ...................................................................... 1 2

e. Assistance in bathing, dressing, grooming, toileting, feeding, and other personal care for the person you care for ................................................................ 1 2

f. Adult daycare for the person you care for................. 1 2

g. Assistance in getting other family members involved in caring for the person you care for ........... 1 2

h. Assistance in administering and monitoring side effects of medicine for the person you care for, etc. .. 1 2

i. In-home respite care ............................................. 1 2

j. Help with money management and financial advice ....... 1 2

k. Other services ...................................................... 1 2

Describe: __________________________________

_________________________________________

l. No additional help needed ...................................... 1 2

22

CRG2. What additional or new kinds of information would be valuable to you as a caregiver? Check yes or no for each one.

Yes No

a. A help line/central place to call to find out what kind of help is available and where to get it .............. 1 2

b. Someone to talk to/counseling services or support groups ..................................................... 1 2

c. Information about how to care for the condition or disability of the person you care for ......................... 1 2

d. Information about changes in laws that might affect your situation .............................................. 1 2

e. Information about how to select a nursing home, group home, assisted living facility, or other care facility .................................................. 1 2

f. Information on how to pay for nursing homes, assisted living facilities, adult day care, and other services ....................................................... 1 2

g. Information on how to deal with agencies (bureaucracies) to get services ............................... 1 2

h. Information on health insurance and/or long-term care insurance ...................................................... 1 2

i. Other information not listed above .......................... 1 2

Describe: __________________________________

_________________________________________

j. No additional information needed ............................ 1 2

POMP Final: Case Management Survey Instrument

(Mail Version)

Office Use Only:


This survey is about the case management services you receive. Your case manager is the person who sets up in-home services, such as homemaker or personal care services for you. The case manager also calls to check on how you are doing, or how you like your services. We would like to ask you a few questions about the person who coordinates/manages your services. It will take between 15 and 30 minutes to complete the questionnaire. We are interested in the length of time you have received case management services and if the service has helped you. Your answers will help the agency make sure that the service meets your needs. Participation in the survey is voluntary and you may skip any question. Your answers will be kept confidential and will not influence the services that you receive.

The first questions are about the case management service you receive from the agency.

CS1. When was the last time you received the case management service? Was it…

Today or yesterday.................................................... 1 More than 1 day, but not more than a week ago ........... 2 More than 1 week, but not more than a month ago ....... 3 More than 1 month ago .............................................. 4 Over 1 year ago ........................................................ 5


CS2. Do you know how to contact your case manager when you need to?

Yes .................................................................................... 1

No ..................................................................................... 2

CS2a. Are you the one who usually speaks to your case manager?

→ Yes ............................................................................ 1 GO TO CS3 → No ............................................................................. 2 GO TO CS17

2

Always UsuallySome-times Rarely Never

CS3. Does your case manager return your phone calls in a timely manner? ............... 1 2 3 4 5

CS4. Does your case manager explain your services in a way that you can understand? .......................................... 1 2 3 4 5

CS5. Does your case manager treat you with respect? ................................................ 1 2 3 4 5

CS6. Does your case manager involve you in discussing and planning your services? ..... 1 2 3 4 5

CS7. Does your case manager do a good job setting up care for you? .......................... 1 2 3 4 5

CS8. Does your case manager help you get services that you did not have before?

Yes .................................................................................... 1

No ..................................................................................... 2

CS9. Is your situation better because of your case manager’s help?

Yes .................................................................................... 1

No ..................................................................................... 2

The next questions ask a few additional questions about the services you received through the case management program.

CS10. How long have you been receiving the case management services?

6 months or less ................................................................. 1



2 to 5 years ........................................................................ 4

More than 5 years ............................................................... 5

3

CS11. How would you rate the overall quality of the case management services you have received? Would you say …

Excellent ............................................................................ 1

Very good .......................................................................... 2

Good ................................................................................. 3

Fair ................................................................................... 4

Poor .................................................................................. 5

CS12. Does your case manager help coordinate all the services you receive?

Yes .................................................................................... 1

No ..................................................................................... 2

CS13. Are you able to select the services you receive?

Yes .................................................................................... 1

No ..................................................................................... 2

CS14. As a result of receiving the case management services, do you have a better idea of where to get information about other services?

Yes .................................................................................... 1

No ..................................................................................... 2

CS15. In general, would you say that the case management service has helped you?

Yes .................................................................................... 1 → GO TO CS15a No ..................................................................................... 2 → GO TO CS16

CS15a. How has the case management service helped you?

___________________________________________________________

___________________________________________________________

___________________________________________________________

CS16. Do you have any recommendations to improve the case management service?

Yes .................................................................................... 1 → GO TO CS16a No ..................................................................................... 2 → GO TO CS17

4

CS16a. What recommendations do you have for improving the case management service?

___________________________________________________________

___________________________________________________________

___________________________________________________________

CS17. Other than case management, what services do you receive? Check all that apply.

Yes No

a. Transportation ...................................................... 1 2

b. Adult Day Services ................................................ 1 2

c. Personal Care Services .......................................... 1 2

d. Chore Services ..................................................... 1 2

e. Legal Assistance ................................................... 1 2

f. Information and Assistance .................................... 1 2

g. Home-Delivered Meals ........................................... 1 2

h. Homemaker/Housekeeper ...................................... 1 2

i. Medication Management ........................................ 1 2

j. Other .................................................................. 1 2

CS18. Are you satisfied with the services you receive?

Yes .................................................................................... 1 No ..................................................................................... 2

CS19. Do the services you receive help you continue to live at home?

Yes .................................................................................... 1 No ..................................................................................... 2

CS20. Are you receiving any other types of assistance such as ...

Yes No

Food Assistance/Food Stamps/SNAP ............................. 1 2

Energy Assistance ...................................................... 1 2

Medicaid ................................................................... 1 2

Housing Assistance .................................................... 1 2

Thank you very much for your time and cooperation. Your responses have been very helpful to us.

POMP Final: Congregate Meals Survey Instrument

(Mail Version)

Office Use Only:


This survey is about the meals program in which you participate. The agency would like to find out about the meals you receive. It will take about 15 to 30 minutes to complete the survey. We are interested in the length of time you have attended the meal program, what you like about the meals, and if the meals have helped you. Your answers will help us make sure that the service meets your needs. Participation in the survey is voluntary and you may skip any question. Your answers will be kept confidential and will not influence the services that you receive.

The first few questions are about the meal program you attend at (AGENCY/PROVIDER NAME).

CM1. When was the last time you ate at the senior center or meal site?


Today or yesterday.................................................... 1

More than 1 day, but not more than a week ago ........... 2

More than 1 week, but not more than a month ago ....... 3

More than 1 month ago .............................................. 4

Over 1 year ago ........................................................ 5

CM2. How long have you been attending the meal program? Would you say…

6 months or less ................................................................. 1



2 to 5 years ........................................................................ 4

More than 5 years ............................................................... 5

CM3. How many days each week do you eat at the senior center or meal site?

|___|___| Number of Days

The following questions are about your eating habits.

CM4. On the days when you eat at the meal site or senior center, how many meals do you usually eat?

|___|___|

CM5. On the days when you don’t eat at the meal site or senior center, how many meals do you usually eat?

|___|___|

2

CM6. Please consider all the food you eat in a day on the days you attend the meal program or senior center. What percentage of all the food you eat in a day is eaten at the meal program or senior center? Would you say…

Less than one-third ............................................................. 1

Between one-third and one-half ............................................ 2

About one-half .................................................................... 3

More than one-half .............................................................. 4

For the next set of questions, we describe the standard serving size for a particular food or group of foods. Please fill in the blank to show how many total servings of each food or group of foods you usually eat each day.

CM7. One serving of fruit is one small piece of fruit, about one-half cup of chopped fruit, or one-half cup of juice.

How many servings of fruit do you usually eat every day?

|___|___|

CM8. One serving of potatoes is one small baked potato or one-half cup mashed or boiled potatoes.

How many servings of potatoes do you usually eat every day?

|___|___|

CM9. One serving of vegetables is about one cup raw vegetables, one-half cup of cooked vegetables, or one-half cup of juice.

Other than potatoes, how many servings of vegetables do you usually eat every day?

|___|___|

CM10. One serving of milk or yogurt, including soy milk or yogurt, is one cup of milk or yogurt. One serving of cheese is 1.5 slices or 1.5 ounces of cheese.

How many servings of milk, cheese, yogurt, or soy milk, soy cheese, or soy yogurt do you usually eat every day?

|___|___|

3

CM11. Beans, nuts, eggs, and tofu are sources of protein in the diet. One serving of beans or tofu is about one-half cup; one serving of peanut butter is two tablespoons; one serving of nuts is one ounce, and a serving of eggs is two eggs.

How many servings of beans, nuts, tofu, or eggs do you usually eat every day?

|___|___|

CM12. One serving of meat, chicken, turkey, or fish is a two to three ounce hamburger patty, chicken breast, or fish fillet.

How many servings of meat, chicken, turkey, or fish do you usually eat every day?

|___|___|

CM13. One serving of bread is one piece of bread, one tortilla, or one small pancake.

How many servings of bread, tortillas, or pancakes do you usually eat every day?

|___|___|

CM14. Cereal, rice, pasta, and noodles are sources of grains in the diet. A serving of cereal is one cup of cold cereal or one-half cup hot cereal; a serving of rice, pasta, or noodles is one-half cup.

How many servings of cereal, rice, pasta, or noodles do you usually eat every day?

|___|___|

CM15. A serving of dessert is one-half slice of pie or cake or two medium cookies.

How many servings of dessert do you usually eat every day?

|___|___|

4

The following questions ask about foods or groups of foods that you eat when you attend the meal program at the senior center or meal site.

CM16. When you eat at the senior center or meal site, do you usually eat the fruit when it is provided?

Yes .................................................................................... 1No ..................................................................................... 2

CM17. When you eat at the senior center or meal site, do you usually eat the potatoes when they are provided?

Yes .................................................................................... 1No ..................................................................................... 2

CM18. When you eat at the senior center or meal site, do you usually eat the vegetables that are provided?

Yes .................................................................................... 1No ..................................................................................... 2

CM19. When you eat at the senior center or meal site, do you usually eat or drink the milk, cheese, yogurt, or soy milk, soy cheese, or soy yogurt that are provided?

Yes .................................................................................... 1No ..................................................................................... 2

CM20. When you eat at the senior center or meal site, do you usually eat the beans, nuts, eggs, or tofu when they are provided?

Yes .................................................................................... 1No ..................................................................................... 2

CM21. When you eat at the senior center or meal site, do you usually eat the meat, turkey, chicken, or fish that is provided?

Yes .................................................................................... 1No ..................................................................................... 2

CM22. When you eat at the senior center or meal site, do you usually eat the bread, tortillas, or pancakes that are provided?

Yes .................................................................................... 1

No ..................................................................................... 2

5

CM23. When you eat at the senior center or meal site, do you usually eat the cereal, rice, pasta, or noodles when they are provided?

Yes .................................................................................... 1

No ..................................................................................... 2

CM24. When you eat at the senior center or meal site, do you usually eat the dessert when it is provided?

Yes .................................................................................... 1

No ..................................................................................... 2

The next questions are about the services you receive at the meal program.

CM25. How would you rate the meal program overall? Would you say…

Excellent ............................................................................ 1

Very good .......................................................................... 2

Good ................................................................................. 3

Fair ................................................................................... 4

Poor .................................................................................. 5

Think about all the foods that you receive from the meal program. Please tell us, how often are you satisfied…


CM26. With the way the food smells ................. 1 2 3 4 5

CM27. With the way the food looks .................. 1 2 3 4 5

CM28. With the way the food tastes ................. 1 2 3 4 5

CM29. With the variety of foods ......................... 1 2 3 4 5

CM30. That the hot foods are hot and cold foods are cold ...................................... 1 2 3 4 5

CM31. With the way the food is cooked ................. 1 2 3 4 5

6

Please answer the following questions about the meal program. Do services received at the meal program help you to…

Yes No

CM32. Eat healthier foods ...................................................... 1 2

CM33. Achieve or maintain a healthy weight ............................. 1 2

CM34. Improve your health .................................................... 1 2

CM35. Feel better .................................................................. 1 2

CM36. See your friends more often ......................................... 1 2

CM37. Continue to live at home .............................................. 1 2

Yes No

CM38. Do you like the meals you get from the meal program? .... 1 2

CM39. Would you recommend the meal program to a friend? ..... 1 2

CM40. As a result of attending the meal program, do you have a better idea of where to get information about other services? .................................................................... 1 2

CM41. While you are there, do you learn food safety tips for cooking and storing food?

Yes .................................................................................... 1

No ..................................................................................... 2

CM42. While you are there, do you learn how to eat more healthful and nutritious foods?

Yes .................................................................................... 1No ..................................................................................... 2

The next questions are about resources.

CM43. Do you know that the congregate meal donation is voluntary?

Yes .................................................................................... 1No ..................................................................................... 2

7

CM44. How do you get to the meal program or senior center?

Public Transportation ........................................................... 1Senior Center/Nutrition Program Transportation ...................... 2Walk .................................................................................. 3Drive ................................................................................. 4Driven by someone ............................................................. 5Other ................................................................................. 6 Describe:_________________________________________

CM45. Are there times when you have not been able to attend the meal program or senior center because you have no way to get there?

Yes .................................................................................... 1

No ..................................................................................... 2

CM46. Do you always have enough money or food assistance/food stamps/SNAP to buy the food you need?

Yes .................................................................................... 1

No ..................................................................................... 2

CM47. During the past month, did you have to choose between buying food or buying medication?

Yes .................................................................................... 1

No ..................................................................................... 2

CM48. During the past month did you have to choose between buying food or paying your rent or utility bills?

Yes .................................................................................... 1

No ..................................................................................... 2

CM49. On one or more days during the past month, did you skip meals because you had no food and no money or food assistance/food stamps/SNAP to buy food?

Yes .................................................................................... 1

No ..................................................................................... 2

CM50. In general, would you say that the meal program has helped you?

Yes .................................................................................... 1

No ..................................................................................... 2 → GO TO CM51

8

CM50a. How has the meal program helped you?

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

CM51. Do you have any recommendations to improve the meal program?

Yes .................................................................................... 1

No ..................................................................................... 2

CM51a. What recommendations do you have for improving the service?

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

Thank you very much for your time and cooperation. Your answers are very important to us in improving the meal program.

POMP Final: Home-Delivered Meals Survey Instrument

(Mail Version)

Office Use Only:


This survey is about the home-delivered meals program. The survey contains questions about the meals that you receive. The survey should take 15 to 30 minutes to complete. We are interested in the length of time you have received home-delivered meals, what you like about the meals, and if the meals have helped you. Your answers will help us make sure that the service meets your needs. Participation in the survey is voluntary and you may skip any question. Your answers will be kept confidential and will not influence the services that you receive.

The first few questions are about the home-delivered meals you receive from (AGENCY/PROVIDER NAME).

HDM1. When was the last time you received a home-delivered meal?


Today or yesterday.................................................... 1More than 1 day, but not more than a week ago ........... 2More than 1 week, but not more than a month ago ....... 3More than 1 month ago .............................................. 4Over 1 year ago ........................................................ 5


HDM2. How long have you been receiving home-delivered meals? Would you say…

6 months or less ................................................................. 1



2 to 5 years ........................................................................ 4

More than 5 years ............................................................... 5

HDM3. How many days each week do you receive home-delivered meals?

|___|___| Number of Days

HDM3a. How many meals do you receive during an average week?

|___|___| Number of Meals


HDM4. On the days that you eat the home-delivered meal, how many meals do you usually eat?


2

HDM5. On the days you don’t eat the home-delivered meal, how many meals do you usually eat?


HDM6. Think about the amount of food you eat from home-delivered meals. On the days you eat a meal from home-delivered meals, what proportion of all the food you eat in a day does this meal represent? Would you say…

Less than one-third ............................................................. 1Between one-third and one-half ............................................ 2About one-half .................................................................... 3More than one-half .............................................................. 4

For the next set of questions, we describe the standard serving size for a particular food or group of foods. Please fill in the blank to show how many total servings of each food or group of foods you usually eat each day.

HDM7. One serving of fruit is one small piece of fruit, about one-half cup of chopped fruit, or one-half cup of juice.


|___|___|

HDM8. One serving of potatoes is one small baked potato or one-half cup mashed or boiled potatoes.


|___|___|

HDM9. One serving of vegetables is about one cup raw vegetables, one-half cup of cooked vegetables, or one-half cup of juice.


|___|___|

3

HDM10. One serving of milk or yogurt, including soy milk or yogurt, is one cup of milk or yogurt. One serving of cheese is 1.5 slices or 1.5 ounces of cheese


|___|___|

HDM11. Beans, nuts, eggs, and tofu are sources of protein in the diet. One serving of beans or tofu is about one-half cup; one serving of peanut butter is two tablespoons; one serving of nuts is one ounce, and a serving of eggs is two eggs.


|___|___|

HDM12. One serving of meat, chicken, turkey, or fish is a two to three ounce hamburger patty, chicken breast, or fish fillet.


|___|___|

HDM13. One serving of bread is one piece of bread, one tortilla, or one small pancake.


|___|___|

HDM14. Cereal, rice, pasta, and noodles are sources of grains in the diet. A serving of cereal is one cup of cold cereal or one-half cup hot cereal; a serving of rice, pasta, or noodles is one-half cup.

How many servings of cereal, rice, pasta or noodles do you usually eat every day?

|___|___|

4

HDM15. A serving of dessert is one-half slice of pie or cake or two medium cookies.


|___|___|

The next few questions ask about foods or groups of foods that you eat from your home-delivered meals.

HDM16. When you eat the home-delivered meals, do you usually eat the fruit when it is provided?

Yes .................................................................................... 1No ..................................................................................... 2

HDM17. When you eat the home-delivered meals, do you usually eat the potatoes when they are provided?

Yes .................................................................................... 1No ..................................................................................... 2

HDM18. When you eat the home-delivered meals, do you usually eat the vegetables that are provided?

Yes .................................................................................... 1No ..................................................................................... 2

HDM19. When you eat the home-delivered meals, do you usually eat or drink the milk, cheese, yogurt, or soy milk, soy cheese, or soy yogurt that are provided?

Yes .................................................................................... 1No ..................................................................................... 2

HDM20. When you eat the home-delivered meals, do you usually eat the beans, nuts, eggs, or tofu when they are provided?

Yes .................................................................................... 1No ..................................................................................... 2

HDM21. When you eat the home-delivered meals, do you usually eat the meat, turkey, chicken, or fish that is provided?

Yes .................................................................................... 1No ..................................................................................... 2

5

HDM22. When you eat the home-delivered meals, do you usually eat the bread, tortillas, or pancakes that are provided?

Yes .................................................................................... 1 No ..................................................................................... 2

HDM23. When you eat the home-delivered meals, do you usually eat the cereal, rice, pasta, or noodles when they are provided?

Yes .................................................................................... 1 No ..................................................................................... 2

HDM24. When you eat the home-delivered meals, do you usually eat the dessert when it is provided?

Yes .................................................................................... 1 No ..................................................................................... 2

The following questions are about the quality of the meals you receive.

HDM25. How would you rate the quality of home-delivered meals overall? Would you say…

Excellent ............................................................................ 1 Very good .......................................................................... 2 Good ................................................................................. 3 Fair ................................................................................... 4 Poor .................................................................................. 5

HDM26. Do the home-delivered meals arrive when expected?

Always ............................................................................... 1 Usually .............................................................................. 2 Sometimes ......................................................................... 3 Seldom .............................................................................. 4 Never ................................................................................ 5

6

Think about all the foods that you receive from home-delivered meals. Please tell us, how often are you satisfied…


HDM27. With the way the food smells .............. 1 2 3 4 5

HDM28. With the way the food looks ............... 1 2 3 4 5

HDM29. With the way the food tastes .............. 1 2 3 4 5

HDM30. With the variety of foods .................... 1 2 3 4 5

HDM31. That the hot foods are hot and cold foods are cold ................................... 1 2 3 4 5

HDM32. With the way the food is cooked .......... 1 2 3 4 5

Please answer the following questions about the home-delivered meals program. Do services received from the home-delivered meals program help you to…

Yes No

HDM33. Eat healthier foods .................................................... 1 2

HDM34. Achieve or maintain a healthy weight ........................... 1 2

HDM35. Improve your health .................................................. 1 2

HDM36. Feel better ................................................................ 1 2

HDM37. Continue to live at home ............................................ 1 2

Please tell us: Yes No

HDM38. Do you like the meals you get from the home-delivered meals? .............................................. 1 2

HDM39. Would you recommend the home-delivered meals to a friend?...................................................... 1 2

HDM40. As a result of receiving home-delivered meals, do you have a better idea of where to get information about other services ................................. 1 2

7


HDM41. Do you know that the home-delivered meal donation is voluntary?

Yes .................................................................................... 1No ..................................................................................... 2

HDM42. Do you always have enough money or food assistance/food stamps/SNAP to buy the food you need?

Yes .................................................................................... 1No ..................................................................................... 2

HDM43. During the past month, did you have to choose between buying food or buying medication?

Yes .................................................................................... 1 No ..................................................................................... 2

HDM44. During the past month did you have to choose between buying food or paying your rent or utility bills?

Yes .................................................................................... 1 No ..................................................................................... 2

HDM45. On one or more days during the past month, did you skip meals because you had no food and no money or food assistance/food stamps/SNAP to buy food?

Yes .................................................................................... 1 No ..................................................................................... 2

HDM46. In general, would you say that the home-delivered meals service has helped you?

Yes .................................................................................... 1No ..................................................................................... 2 → GO TO HDM47

8

HDM46a. How has the home-delivered meals service helped you?

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

HDM47. Do you have any recommendations to improve the home-delivered meals service?

Yes .................................................................................... 1

No ..................................................................................... 2

HDM47a. What recommendations do you have for improving the service?

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

Thank you very much for your time and cooperation. Your answers are very important to us in improving the home-delivered meals services.

POMP Final: Transportation Survey Instrument

(Mail Version)

Office Use Only:


This survey is about the transportation services you receive. We would like you to answer questions about these services. It will take between 15 and 30 minutes to answer this survey. We are interested in the length of time you have received transportation services and whether the transportation services have been helpful. Your answers will help make sure that the services meet your needs. Participation in the survey is voluntary and you may skip any question. Your answers will be kept confidential and will not influence the services that you receive.

The first few questions are about the transportation service you receive.

TR1. When was the last time you used the transportation services?

Today or yesterday.................................................... 1More than 1 day, but not more than a week ago ........... 2More than 1 week, but not more than a month ago ....... 3More than 1 month ago .............................................. 4Over 1 year ago ........................................................ 5


TR2. How long have you been receiving transportation services? Would you say…

6 months or less ................................................................. 1More than 6 months, but less than 1 year .............................. 2At least 1 year but less than 2 years ...................................... 32 to 5 years ........................................................................ 4More than 5 years ............................................................... 5

TR3. How often do you use the transportation service?

5 or more times per week .................................................... 13 to 4 times per week .......................................................... 2Once per week .................................................................... 31 to 2 times per month ........................................................ 4Less than once per month .................................................... 5

TR4. In an average month, would you say you rely on this transportation service for:

Just a few of your local trips ................................................. 1About 1/4 of all your local trips ............................................. 2About 1/2 of all your local trips ............................................. 3About 3/4 of all your local trips ............................................. 4Nearly all of your local trips .................................................. 5

2

TR5. Which of the following best describes where you get on the vehicle?

Several blocks away ............................................................ 1

Down the block ................................................................... 2

My driveway/In front of my residence .................................... 3

The driver comes to my door ................................................ 4

At the senior center ............................................................. 5

For the next few questions, please tell me how frequently these statements apply to your overall experiences with the transportation service. Please select one of these five responses: Always, Usually, Sometimes, Rarely, Never).


TR6. The drivers pick me up when they are supposed to. Would you say .................. 1 2 3 4 5

TR7. The drivers are polite ............................ 1 2 3 4 5

TR8. The vehicles are easy to get into and out of ................................................. 1 2 3 4 5

TR9. The vehicles are comfortable. ................ 1 2 3 4 5

TR10. We arrive at our destinations on time ..... 1 2 3 4 5

TR11. The trips take too long .......................... 1 2 3 4 5

TR12. The transportation service takes me to the places I want or need to go .............. 1 2 3 4 5

TR13. I get rides at the times and on the days I need them ........................................ 1 2 3 4 5

TR14. Do you need help getting into and out of your home?

Yes .................................................................................... 1

No ..................................................................................... 2 → GO TO TR15

TR14a. Does the driver or aide help you get into and out of your home?

Yes ............................................................................ 1

No ............................................................................. 2

TR15. Do you need help getting into or out of the vehicle?

3

Yes .................................................................................... 1

→No ..................................................................................... 2 GO TO TR16

TR15a. Does the driver or aide help you get into or out of the vehicle?

Yes ............................................................................ 1

No ............................................................................. 2

TR16. Do you get around more than you did before you had this service?

Yes .................................................................................... 1

No ..................................................................................... 2

TR17. Would you recommend this transportation service to a friend?

Yes .................................................................................... 1

No ..................................................................................... 2

TR18. Do the services you receive help you continue to live at home?

Yes .................................................................................... 1

No ..................................................................................... 2

TR19. Next, how would you rate the transportation service that you received? Would you say...

Excellent ............................................................................ 1

Very Good .......................................................................... 2

Good ................................................................................. 3

Fair ................................................................................... 4

Poor .................................................................................. 5

4

TR20. Do you use the transportation service to get to: Yes No

a. Doctors and health care providers ........................... 1 2

b. Shopping/Hairdresser ............................................ 1 2

c. Volunteer activities ............................................... 1 2

d. Senior center........................................................ 1 2

e. Lunch program ..................................................... 1 2

f. Friends, neighbors, and relatives ............................ 1 2

g. Social events and recreation activities ..................... 1 2

h. Clubs and meetings ............................................... 1 2

i. Religious services .................................................. 1 2

j. Work ................................................................... 1 2

k. Some place else? .................................................. 1 2

Describe: __________________________________

TR21. In general, would you say that the transportation service has helped you?

Yes .................................................................................... 1

→ No ..................................................................................... 2 GO TO TR22

TR21a. How has the transportation service helped you?

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

TR22. Do you have any recommendations to improve the transportation service?

Yes .................................................................................... 1

→No ..................................................................................... 2 GO TO TR23

5

TR22a. What recommendations do you have for improving the service?

_________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________

These next questions are about getting around outside your home.

TR23. Is there a car or other personal motor vehicle in working condition in this household?

Yes .................................................................................... 1

No ..................................................................................... 2 → GO TO TR25

TR24. Do you ever drive that car?

Yes .................................................................................... 1 → If yes, this concludes the transportation survey.

No ..................................................................................... 2

TR25. Excluding taxi services, is public transportation service available in this community, such as a regular bus line, rapid transit, subway, or street car?

Yes .................................................................................... 1

No ..................................................................................... 2 → If no, this concludes the transportation survey.

TR26. Do you ever use public transportation?

Yes .................................................................................... 1


TR27. Do you have a physical, mental, or emotional condition that makes public transportation hard to use?

Yes .................................................................................... 1


6

TR27a. Do you need the assistance of another person to use public transportation?

Yes ............................................................................ 1No ............................................................................. 2

Thank you very much for your time and cooperation. Your answers are very important to us in improving transportation services.

POMP Final: Additional Services Received Module

(Mail Version)

Office Use Only:


The next questions are about additional help you may have received.

Yes No

AS1. In the past year, have you attended a lunch program at a senior center or other meal site? A lunch program, or Congregate Meals are meals provided in a group setting, such as at a senior center .................................. 1 2

AS2. In the past year, have you received Meals on Wheels? Meals on Wheels or Home-Delivered Meals are meals that are usually delivered to eat at home ........................ 1 2

AS3. In the past year, have you received homemaker or housekeeping services? Homemaker or housekeeping services are services that may include help with doing light housework, laundry, preparing meals or shopping ..... 1 2

AS4. In the past year, have you received case management services? When someone receives case management, they have a case manager who may set up in-home services, such as homemaker or personal care services for them. The case manager may also call to check on how they are doing, or how they like the services ............. 1 2

AS5. In the past year, have you received transportation services? Transportation is a bus or other vehicle that picks people up and takes them places such as the doctor, the senior center, or shopping. Includes recreational trips .......................................................... 1 2

AS6. In the past year, have you received adult day care services? Adult day care or adult day health is when people go to a place and spend the day........................... 1 2

AS7. In the past year, have you received personal care services? Personal care services are help with care like dressing or bathing ................................................. 1 2

AS8. In the past year, have you received chore services? Chore services help with heavier housecleaning and yard work .................................................................... 1 2

AS9. In the past year, have you received legal assistance? Legal assistance may help with making a will or understanding a bill and other legal matters. Remember, we are talking about services received from this agency .......................................................... 1 2

2

Yes No

AS10. In the past year, have you received information and assistance services? Information and assistance helps people find out about services that are available to them. Remember, we are talking about services received from this agency .................................................................. 1 2

AS11. Do you have a nutrition counselor who gives individual advice on what you should eat based on general health, chronic conditions, medications, and your usual food choices? Remember, we are talking about services received from this agency.............................................. 1 2

AS12. Have you received health screenings such as blood pressure checks or mammograms other than those from your own doctor? Remember, we are talking about services received from this agency ........................ 1 2

AS13. Have you received flu shots, pneumonia shots, or other immunizations other than those from your own doctor? Remember, we are talking about services received from this agency .................................................................. 1 2

AS14. Have you taken exercise or fitness classes or do you use the exercise equipment at a senior center or other program for older adults? Remember, we are talking about services received from this agency ........................ 1 2

AS15. Do you receive help managing your medications, understanding how much to take, how often and whether it works with your other medicines? ................... 1 2

AS16. In the past year, have you received help getting benefits, such as food stamps, Medicaid, SSI, or Social Security? ............................................................ 1 2

AS17. Overall, how would you rate the group of services you receive? Would you say…

Excellent ............................................................................ 1Very good .......................................................................... 2Good ................................................................................. 3Fair ................................................................................... 4Poor .................................................................................. 5

3

AS18. Are you receiving any other types of assistance, such as…

Yes No

a. Food Assistance/Food Stamps/SNAP ........................ 1 2

b. Energy Assistance ................................................. 1 2

c. Medicaid .............................................................. 1 2

d. Housing Assistance ............................................... 1 2

Now, I would like to ask about how these services help you.

AS19. As a result of the services you receive, are you able to live independently?

Yes .................................................................................... 1

No ..................................................................................... 2

AS20. As a result of the services you receive, are you better able to care for yourself?

Yes .................................................................................... 1

No ..................................................................................... 2

POMP Final: Demographics Module

(Mail Version)

Office Use Only:



D1. What is your gender?

Male .................................................................................. 1Female .............................................................................. 2

D2. In what year were you born?

|___|___|___|___| Year

D3. What is your highest education level?

Less than high school diploma .............................................. 1High school diploma ............................................................ 2Some college, including associate degree ............................... 3Bachelor’s degree ................................................................ 4Some post-graduate work or advanced degree ....................... 5

D4. Are you Spanish, Hispanic or Latino?

Yes .................................................................................... 1No ..................................................................................... 2

D5. What is your race?

a. American Indian or Alaskan Native ................................... 1b. Asian ............................................................................ 2c. Black or African-American ............................................... 3d. White/Caucasian ............................................................ 4e. Native Hawaiian/Other Pacific Islander .............................. 5f. Other Race .................................................................... 6

D6. What is your marital status?

Now married ....................................................................... 1Widowed ............................................................................ 2Divorced ............................................................................ 3Separated .......................................................................... 4Never married .................................................................... 5

2

D7. Where is your home located? Would you say…

In a city ............................................................................. 1

In a suburban area .............................................................. 2

In a rural area .................................................................... 3

D8. We’d like to ask about who lives in your household. Do you…

Yes No

a. Live alone ............................................................ 1 2 IF “Yes,” GO TO D10 b. Live with your spouse ............................................ 1 2

c. Live with your children ........................................... 1 2

d. Live with other relatives ......................................... 1 2

e. Live with domestic partner ..................................... 1 2

f. Live with non-relatives other than domestic partner .. 1 2

D9. How many people live in your household, including yourself?

|___|___| Number of Household Members

D10. Thinking about the total combined income from all sources for all persons in your household, including income from jobs, Social Security, retirement income, public assistance, and all other sources was your total household annual income during the last calendar year above or below $20,000?

At or below $20,000 ($1,666 per month or less) ..................... 1 GO TO D10a Above $20,000 ($1,667 per month or more) .......................... 2 GO TO D10b

D10a. Which category best describes your total household annual income during the last calendar year? Would you say…

$5,000 or less ($417 or less per month)......................... 1 This concludes this portion of the survey.

$5,001 - $10,000 ($418 to $833 per month) .................. 2

$10,001 - $15,000 ($834 to $1,250 per month) .............. 3

$15,001 - $20,000 ($1,251 to $1,666 per month) ........... 4

3

D10b. Which category best describes your total household annual income during the last calendar year? Would you say…

$20,001 - $25,000 ($1,667 to $2,083 per month) ........... 1$25,001 - $30,000 ($2,084 to $2,500 per month) ........... 2$30,001 - $35,000 ($2,501 to $2,917 per month) ........... 3$35,001 - $40,000 ($2,918 to $3,333 per month) ........... 4$40,001 - $50,000 ($3,334 to $4,167 per month) ........... 5Over $50,000 ($4,168 per month or more) ..................... 6

.........

..............

.................

POMP Final: Physical Functioning and Health Module

(Mail Version)

Office Use Only:


These next questions are about your health.

PF1. In general, would you say your health is:

Excellent ............................................................................ 1

Very good .......................................................................... 2

Good ................................................................................. 3

Fair ................................................................................... 4

Poor .................................................................................. 5

PF2. Do you use any of the following aids?

If “Yes,” have you used them for

6 months or longer?

Yes No Yes No

PF2a. A cane, crutches, or a walkerPF2a. A cane, crutches, or a 1 2 1 2

PF2b. A wheelchair, electric scooter, etc . 1 2 1 2

PF2c. A hearing aid 1 2 1 2

PF2d.

............

Other (e.g., grab bar,

....................

shower chair, shower bench, etc.) 1 2 1 2

PF3. About how many different prescription medications do you take every day?

|___|___|

PF4. In the past 12 months, did you have to stay overnight in a nursing home or rehabilitation center?

Yes .................................................................................... 1

No ..................................................................................... 2

PF5. In the past 12 months, did you have to stay overnight in a hospital?

Yes .................................................................................... 1No ..................................................................................... 2

PF6. In the past 12 months, did you receive treatment in an emergency room?

Yes .................................................................................... 1No ..................................................................................... 2

.......................

.........................

...................

......................

......

..........................

.............................

..............................................................

................................................................

................................................

............................................

..

..........................................

................................................

...........................................

..

..

2

This question asks about common activities of daily life and whether you usually need assistance with them. This does not include the effects of temporary conditions. If you use an aid or assistive device, please indicate if you still have difficulty when using the aid.

Because of a physical or mental health condition, do you have difficulty...

Yes No

If “Yes,” do you need the help of another person?

Yes No

PF7. Getting around INSIDE the home 1 2 1 2

PF8. Getting around OUTSIDE the home, for example to shop or visit a doctor’s office 1 2 1 2

PF9. Getting in or out of a bed or a chair ....................... 1 2 1 2

PF10. Taking a bath or shower ....................................... 1 2 1 2

PF11. Dressing ............................................................. 1 2 1 2

PF12. Walking 1 2 1 2

PF13. Eating 1 2 1 2

PF14. Using or getting to the toilet ................................. 1 2 1 2

PF15. Keeping track of money or bills ............................. 1 2 1 2

PF16.

Preparing meals

.. 1 2 1 2

PF17. Doing light housework, such as washing dishes or sweeping a floor 1 2 1 2

PF18. Doing heavy housework, such as scrubbing floorsand washing windows 1 2 1 2

PF19. Taking the right amount of prescribed medicineat the right time 1 2 1 2

PF20. Using the telephone 1 2 1 2

3

PF21. Have you ever been told by a doctor, nurse, or other health care professional that you have...

Yes No

a. Arthritis or rheumatism .......................................... 1 2

b. High blood pressure or hypertension ....................... 1 2

c. A heart attack, coronary heart disease, angina, congestive heart failure, or other heart problems ...... 1 2

d. High cholesterol .................................................... 1 2

e. Diabetes or high blood sugar .................................. 1 2

f. Allergies, asthma, emphysema, chronic bronchitis, or other breathing or lung problems ........................ 1 2

g. Cancer or a malignant tumor, excluding minor skin cancer........................................................... 1 2

h. Stroke ................................................................. 1 2

i. Anemia ................................................................ 1 2

j. Osteoporosis ........................................................ 1 2

k. Kidney disease ..................................................... 1 2

l. Eye or vision conditions such as glaucoma, cataracts, macular degeneration or other medical conditions [Does not include only wears glasses or contacts.] .... 1 2

m. Oral health/tooth or mouth problems ...................... 1 2

n. Hearing problems.................................................. 1 2

o. Emotional, nervous, or psychiatric problems ............. 1 2

p. Memory related disease such as Alzheimer’s or dementia ............................................................. 1 2

q. Seizures or epilepsy .............................................. 1 2

r. Parkinson’s .......................................................... 1 2

s. Persistent pain, aching, stiffness or swelling around a joint? [Includes broken bones and sprained muscles, and bad backs, knees, shoulders, etc.] ....... 1 2

t. Multiple Sclerosis .................................................. 1 2

u. A serious problem with urinary incontinence ............. 1 2

v. Something else? ................................................... 1 2

Please describe: ____________________________

POMP Final: Social and Emotional Well-Being Module

(Mail Version)

Office Use Only:


These next questions are about your overall social and emotional well-being.

SE1. During an average week, how many days are you in touch by phone, Internet (email), or in person with a friend, neighbor, or relative who does not live with you?

None ................................................................................. 1

One day ............................................................................. 2

Two days ........................................................................... 3

Three days ......................................................................... 4

Four days ........................................................................... 5

Five days ........................................................................... 6

Six days ............................................................................. 7

Every day ........................................................................... 8

SE2. Thinking about how often you are in touch with friends, neighbors, and relatives is this ...

Not enough (Would like to do more) ...................................... 1

About enough ..................................................................... 2

Too much ........................................................................... 3

SE3. During an average week, how many days do you leave home to go to a movie, sports event, club meeting, class, or place of worship?

None ................................................................................. 1

One day ............................................................................. 2

Two days ........................................................................... 3

Three days ......................................................................... 4

Four days ........................................................................... 5

Five days ........................................................................... 6

Six days ............................................................................. 7

Every day ........................................................................... 8

SE4. Regarding your present social activities, do you feel that you are doing ...

Not enough (Would like to do more) ...................................... 1

About enough ..................................................................... 2

Too much ........................................................................... 3

2

SE5. In general, how would you describe your emotional well-being?

Excellent ............................................................................ 1Very good .......................................................................... 2Good ................................................................................. 3Fair ................................................................................... 4Poor .................................................................................. 5

SE6. During the past 30 days, how often have you had difficult or painful feelings such as stress, grief, worry, anger or loneliness?

Always ............................................................................... 1Usually .............................................................................. 2Sometimes ......................................................................... 3Rarely ................................................................................ 4Never ................................................................................ 5

SE7. During the past 30 days, to what extent have feelings such as stress, grief, worry, anger or loneliness interfered with your normal social activities with family, friends, neighbors, or groups?

Always ............................................................................... 1Usually .............................................................................. 2Sometimes ......................................................................... 3Rarely ................................................................................ 4Never ................................................................................ 5

POMP Final: Caregiver Services Survey Instrument(Telephone Version)

Office Use Only:


Hello. My name is ____________________________. I am calling from the (name of AAA). I understand that you receive caregiver services. We would like to ask you a few questions about the services that you receive. The interview will take about 30 minutes. We are interested in the length of time you have received caregiver services and whether the caregiver services have been helpful. Your answers will help us make sure that the services meet your needs. Participation in the interview is voluntary and you may skip any question. Your answers will be kept confidential and will not influence the services that you receive.

CR1. Are you still caring for (care recipient’s name) or (someone 60 years of age or older)?

Yes .................................................................................... 1 GO TO CR2 No ..................................................................................... 2 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

CR1a. Could you tell me what happened to change your caregiving situation? DO NOT READ LIST. CHECK ALL THAT APPLY.

a. Care recipient died ................................................. 1 b. Care recipient was placed in a nursing home .............. 2 c. Care recipient was placed in an assisted living

facility ................................................................... 3 d. Care recipient was placed in a family type

group home (family care home) ............................... 4 e. Care recipient is getting help temporarily from

a different caregiver ............................................... 5 f. Care recipient has a different permanent

caregiving arrangement .......................................... 6 g. Care recipient got better and no longer needs

help ...................................................................... 7 h. Care recipient’s needs exceed caregiver’s

capacity to help ...................................................... 8 i. Caregiver’s health status has declined ....................... 9 j. Caregiver’s employment status has changed .............. 10 k. Caregiver’s family situation has changed ................... 11 l. Other reason ......................................................... 91 Please specify: ______________________________

__________________________________________

Refused ...................................................................... -7 Don’t Know ................................................................. -8

END INTERVIEW

2

CR2. When was the last time you received caregiver support services?

Today or yesterday ..................................................... 1 More than 1 day, but not more than a week ago ............. 2 More than 1 week, but not more than a month ago ......... 3 More than 1 month ago ............................................... 4 Over 1 year ago .......................................................... 5

Thank you, but the focus of this survey is on people who have used the service within the past year. END INTERVIEW

Refused ..................................................................... -7 END INTERVIEW Don’t Know ................................................................ -8

CR3. How long have you been receiving caregiver services? Would you say…

6 months or less ................................................................. 1 More than 6 months, but less than 1 year .............................. 2 At least 1 year, but less than 2 years ..................................... 3 2 to 5 years ........................................................................ 4 More than 5 years ............................................................... 5 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

CR4. What is (care recipient’s name) relationship to you? (Care recipient’s name) is your… READ CATEGORIES IF NEEDED

Husband ............................................................................ 1 Wife .................................................................................. 2 Domestic partner ................................................................ 3 Father ................................................................................ 4 Mother ............................................................................... 5 Grandfather ........................................................................ 6 Grandmother ...................................................................... 7 Brother .............................................................................. 8 Sister ................................................................................ 9 Uncle ................................................................................. 10 Aunt .................................................................................. 11 Son ................................................................................... 12 Son-in-Law ......................................................................... 13 Daughter............................................................................ 14 Daughter-in-Law ................................................................. 15 Other relative (not mentioned above) .................................... 16 Friend or neighbor or another person ..................................... 17 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

3

CR5. Has someone at (agency’s name) helped you or given you information to connect you to the services and resources that you need as a caregiver?

Yes .................................................................................... 1 No ..................................................................................... 2 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

CR6. Have you received respite care, which allows you a brief break while temporary care is provided to (care recipient’s name), either in your home or someplace else?


CR7. Have you received caregiver training or education, including participation in support groups, to help you make decisions and solve problems in your role as a caregiver?


CR8. Has the (agency’s name) provided you with any supplemental services to help you provide care, such as INSERT A DESCRIPTION OF LOCAL SERVICES, E.G. HOME MODIFICATIONS, NUTRITIONAL SUPPLEMENTS SUCH AS ENSURE OR BOOST, ASSISTIVE DEVICES SUCH AS CANES OR WALKERS, PERSONAL EMERGENCY RESPONSE SYSTEM, SPECIALIZED EQUIPMENT SUCH AS SLEEP APNEA MACHINES OR HOSPITAL BEDS, STIPENDS, ETC.?


4

CR9. Of the caregiver services you received, which one service was the most helpful? READ ONLY WHEN THE RESPONDENT NEEDS REMINDER. CHECK ONLY ONE.

Help or information connecting you to services and resources ....................................................................... 1

Respite Care Services .......................................................... 2 Caregiver Training or Education, including Counseling or a

Support Group, or ........................................................... 3 Other Supplemental Support Services or Assistance ................ 4 (Specify) ________________________________________ Refused ............................................................................. -7 Don’t Know ........................................................................ -8

CR10. As a result of the caregiver services, do you…

Yes 1 1

No 2 2

Refused

-7 -7

Don’t Know

-8 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

a. Have more time for personal activities ..................... b. Feel less stress ..................................................... c. Have a clearer understanding of how to get

the services you and (care recipient) need ............... d. Know more about (care recipient’s) condition

or illness .............................................................. e. Feel more confident in providing care to

(care recipient’s name) ..........................................

CR11. Would (care recipient’s name) have been able to continue to live in the same home if caregiver services had not been provided?

Yes .................................................................................... 1 GO TO CR12 No ..................................................................................... 2 GO TO CR11a Refused ............................................................................. -7 Don’t Know ........................................................................ -8

GO TO CR12

CR11a. Where would (care recipient’s name) be living? DO NOT READ LIST. CHECK ONLY ONE ANSWER.

In your (caregiver’s) home ........................................... 1 In the home of another family member or friend ............. 2 In an assisted living facility ........................................... 3 In a nursing home ....................................................... 4 Care recipient would have died...................................... 5 Other ......................................................................... 91 (Specify) ______________________________________ Refused ...................................................................... -7 Don’t Know ................................................................. -8

5

CR12. Thinking about the caregiver services that you have received, how would you rate these services? Would you say…

Excellent ............................................................................ 1 Very good .......................................................................... 2 Good ................................................................................. 3 Fair ................................................................................... 4 Poor .................................................................................. 5 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

CR13. Would you recommend these services to a friend?


CR14. Have the caregiver services enabled you to provide care for a longer period of time than would have been possible without these services?


CR15. In general, would you say that the caregiver service has helped you?

Yes .................................................................................... 1 GO TO CR15a No ..................................................................................... 2 Refused ............................................................................. -7 GO TO CR16 Don’t Know ........................................................................ -8

CR15a. How has the caregiver service helped you?

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

6

CR16. Do you have any recommendations to improve the caregiver service?

Yes .................................................................................... 1 GO TO CR16a No ..................................................................................... 2 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

GO TO ADDITIONAL MODULES OR CLOSE

CR16a. What recommendations do you have for improving the service?

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

Note to Interviewer:

Additional modules may be used with this survey:

1. Module A: Care Provided Module

2. Module B: Burdens and Rewards Module

3. Module C: Impact on Employment Module

4. Module D: Health of Caregiver Module

5. Module E: Demographics Module

6. Module F: Health and Physical Functioning of Care Recipient Module

7. Module G: Service and Information Needs

Thank you very much for your time and cooperation. Your answers are very important to us in improving the caregiver services.

7

Module A: Care Provided

In this section of the survey, we would like to obtain some basic information about how much care you provide to (care recipient’s name).

CRA1. How long have you been caring for (care recipient’s name)?

|___|___| Years |___|___| Months Refused ............................................................................. -7 Don’t Know ........................................................................ -8

CRA2. Thinking about all the family members or friends who provide help, care, or supervision for (care recipient’s name), what proportion of the care do you provide during a typical week? READ LIST. CHECK ONLY ONE. Would you say…

Less than one-quarter .......................................................... 1 About one-quarter ............................................................... 2 About one-half .................................................................... 3 About three-quarters ........................................................... 4 All or almost all of the care ................................................... 5 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

CRA3. Does (care recipient’s name) live with you?

Yes .................................................................................... 1 GO TO CRA5 No ..................................................................................... 2 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

CRA4. Does (care recipient’s name) live alone?


GO TO NEXT MODULE

8

CRA5. In your judgment can (care recipient’s name) be left alone (meaning he/she does not require 24 hour help/supervision)? Would you say…

Yes, (care recipient) can be left alone for extended periods with no concerns .................................................. 1

Yes, (care recipient) can be left alone but needs to be checked on in person several times a day ...................... 2

Yes, (care recipient) can be left alone, but only for short periods of time (2 hours or less) ............................... 3

No, (care recipient) cannot be left alone and needs 24-hour supervision......................................................... 4

Refused ............................................................................. -7 Don’t Know ........................................................................ -8

GO TO NEXT MODULE

GO TO NEXT MODULE

CRA5a. Are you responsible for providing help or supervision to (care recipient’s name) on a 24-hour basis?


GO TO NEXT MODULE

CRA5b. Please tell me how you would rate the intensity level of the 24-hour care you currently provide:

1 = The care provided over a 24-hour period is not very intense.

5 = The care provided over a 24-hour period is very intense.

1 2 3 4 5 Least intensity Greatest intensity

9

Module B: Burdens and Rewards of Caregiving

The next group of questions ask about the rewards and burdens you may feel as a caregiver.

CRB1. I would like to ask you about positive aspects of caregiving and give you some choices for answers. Please choose the answer that best tells how you feel.

Always Usually Some-times Rarely Never Refused

Don’t Know

Does Not

Apply

a. As a caregiver, how often do you feel that you are helping (care recipient’s name) continue to live at home.......... 1 2 3 4 5 -7 -8 -9

b. How often does being a caregiver for (care recipient’s name) give you the joy of spending time with someone you care about ....................... 1 2 3 4 5 -7 -8 -9

c. How often does being a caregiver provide you with a sense of accomplishment ........ 1 2 3 4 5 -7 -8 -9

d. How often does providing care for (care recipient’s name) give you the satisfaction of knowing that they are receiving the care and attention they need .......... 1 2 3 4 5 -7 -8 -9

e. How often do you feel that (care recipient’s name) appreciates the care that you are providing for them ............ 1 2 3 4 5 -7 -8 -9

f. As a caregiver, how often do you feel you are fulfilling your duty by caring for (care recipient’s name) ................... 1 2 3 4 5 -7 -8 -9

10

CRB2. In your experience as a caregiver, what is the one most positive aspect of caregiving? READ LIST. CHECK ONLY ONE.

Helping your care recipient live at home ................................ 1 Spending time with someone you care about .......................... 2 Feeling a sense of accomplishment ........................................ 3 Satisfaction that care and attention are received ..................... 4 Being appreciated, or ........................................................... 5 Fulfilling a duty ................................................................... 6 None ................................................................................. 7 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

CRB3. Now I would like to ask you about potential difficulties you may face in caring for (care recipient’s name). Please respond to each of the following questions with one of the options provided. In your experience as a caregiver, how often do you feel that…

Always Usually Some- times Rarely Never Refused

Don’t Know

Does Not

Apply

a. Caregiving creates a financial burden for you........ 1 2 3 4 5 -7 -8 -9

b. Caregiving does not leave you enough time for yourself .............................. 1 2 3 4 5 -7 -8 -9

c. Caregiving does not leave enough time for your family ................................ 1 2 3 4 5 -7 -8 -9

d. Caregiving interferes with your work ........................... 1 2 3 4 5 -7 -8 -9

e. Caregiving negatively affects your health ............... 1 2 3 4 5 -7 -8 -9

f. Caregiving conflicts with your social life ..................... 1 2 3 4 5 -7 -8 -9

g. Caregiving causes you stress ................................ 1 2 3 4 5 -7 -8 -9

11

CRB4. What is the greatest difficulty you have faced in your caregiving? READ LIST. CHECK ONLY ONE.

Would you say caregiving:

Creates a financial burden .................................................... 1 Doesn’t leave enough time for yourself .................................. 2 Doesn’t leave enough time for your family .............................. 3 Interferes with your work ..................................................... 4 Creates or aggravates health problems .................................. 5 Conflicts with your social life ................................................. 6 Creates stress ..................................................................... 7 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

12

Module C: Impact on Employment

CRC1. Have you ever been employed?

Yes .................................................................................... 1 No ..................................................................................... 2

GO TO NEXT MODULE


CRC2. What is your current employment status? Are you …

Working full time ................................................................. 1 GO TO CRC3Working part time ............................................................... 2 Retired............................................................................... 3 Not working ........................................................................ 4 Refused ............................................................................. -7 GO TO NEXT

MODULE Don’t Know ........................................................................ -8

CRC2a. Did your caregiving responsibilities cause you to quit work or retire early?

Yes .................................................................................... 1 GO TO NEXT MODULE

No ..................................................................................... 2 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

CRC3. Has providing care for (care recipient’s name) ever interfered with your employment?

Yes .................................................................................... 1 No ..................................................................................... 2

GO TO NEXT MODULE Refused ............................................................................. -7

Don’t Know ........................................................................ -8

13

CRC4. Because of providing care for (care recipient’s name), have you ... READ LIST AND CHECK ALL THAT APPLY.

Don’t Yes No Refused Know

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

a. Taken a less demanding job ...................................

b. Changed from full-time to part-time work ................

c. Reduced your official working hours ........................

d. Lost some of your employment fringe benefits ..........

e. Had time conflicts between working and caregiving ...

f. Used your vacation time to provide care ..................

g. Taken a leave of absence to provide care .................

h. Lost a promotion ...................................................

i. Worked less than your normal number of hours last month ...........................................................

j. Other ..................................................................

(Specify) __________________________________

_________________________________________

14

Module D: Health of Caregiver

CRD1. Do you have any kind of health problem, physical condition, or disability that affects the kind or amount of care that you can provide to (care recipient’s name)?


GO TO NEXT MODULE

CRD1a. What is that problem, condition, or disability? DO NOT READ RESPONSES. CHECK ALL THAT APPLY AND PROBE: “Is there anything else?”

1. Back problems and other joint problems/Arthritis ................ 1 2. Heart problems/High Blood Pressure/Hypertension/Stroke ... 2 3. Diabetes ........................................................................ 3 4. Allergies/Asthma/Other breathing/Lung problems ............... 4 5. Mental health (anxiety, fear, depression, emotional problems) ........................................................ 5 6. Eye problems .................................................................. 6 7. Other ............................................................................. 91 (Specify) _______________________________________ Refused ............................................................................. -7 Don’t Know ........................................................................ -8

CRD2. Have your caregiving activities created or worsened any of these conditions, problems, or disabilities?


15

Module E: Demographics


CRE1. ASK IF NOT OBVIOUS. What is your gender?

Male .................................................................................. 1 Female .............................................................................. 2 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

CRE2. In what year were you born?

|___|___|___|___| Year Refused ............................................................................. -7 Don’t Know ........................................................................ -8

CRE3. What is your highest education level?

Less than high school diploma .............................................. 1 High school diploma ............................................................ 2 Some college, including associate degree ............................... 3 Bachelor’s degree ................................................................ 4 Some post-graduate work or advanced degree ....................... 5 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

CRE4. Are you Spanish, Hispanic, or Latino?


16

CRE5. What is your race? (CHECK ALL THAT APPLY.)

a. American Indian or Alaskan Native ................................... 1 b. Asian ............................................................................ 2 c. Black or African-American ............................................... 3 d. White/Caucasian ............................................................ 4 e. Native Hawaiian/Other Pacific Islander.............................. 5 f. Other race .................................................................... 6 (Specify) _______________________________________ g. Refused ........................................................................ -7 h. Don’t Know ................................................................... -8

CRE6. What is your marital status?

Now married ....................................................................... 1 Widowed ............................................................................ 2 Divorced ............................................................................ 3 Separated .......................................................................... 4 Never married .................................................................... 5 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

CRE7. Where is your home located? Would you say…

In a city ............................................................................. 1 In a suburban area .............................................................. 2 In a rural area .................................................................... 3 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

CRE8. How many people live in your household, including yourself?

|___|___| Number of Household Members Refused ............................................................................. -7 Don’t Know ........................................................................ -8

CRE9. How many persons total are you caring for, not counting (care recipient’s name)?

|___|___| Number of Persons Refused ............................................................................. -7 Don’t Know ........................................................................ -8

17

CRE10. Thinking about the total combined income from all sources for all persons in this household, was your total household annual income during the past year above or below $20,000? (IF NEEDED: including income from jobs, Social Security, retirement income, public assistance, and all other sources)

Below $20,000 .................................................................... 1 → GO TO CRE11 Above $20,000 ................................................................... 2 → GO TO CRE12 Refused ............................................................................. -7 Don’t Know ........................................................................ -8


$10,000 or less ................................................................... 1 $10,001 to $15,000 ............................................................. 2 $15,001 to $20,000 ............................................................. 3 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

GO TO CRE13


$20,001 to $30,000 ............................................................. 1 $30,001 to $40,000 ............................................................. 2 $40,001 to $50,000 ............................................................. 3 Over $50,000 ..................................................................... 4 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

CRE13. ASK IF NOT OBVIOUS. What is the gender of (care recipient’s name)?

Male .................................................................................. 1 Female .............................................................................. 2 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

CRE14. What is the age of (care recipient’s name)?

|___|___|___| Years Refused ............................................................................. -7 Don’t Know ........................................................................ -8

18

Module F: Health and Physical Functioning of Care Recipient

CRF1. Does (care recipient) have difficulty getting around inside the home?


GO TO CRF2

CRF1a. Does (he or she) need the help of another person to perform this activity?

Yes ............................................................................ 1 No ............................................................................. 2 Refused ...................................................................... -7 Don’t Know ................................................................. -8

CRF2. Does (he or she) have difficulty going outside the home, for example to shop or visit a doctor’s office?


GO TO CRF3



19

CRF3. Does (care recipient) have difficulty getting in or out of bed or a chair?


GO TO CRF4



CRF4. Does (he or she) have difficulty when taking a bath or shower?

Yes .................................................................................... 1 No ..................................................................................... 2 Refused ............................................................................. -7 GO TO CRF5 Don’t Know ........................................................................ -8



CRF5. Does (care recipient) have difficulty when dressing?


GO TO CRF6



20

CRF6. Does (he or she) have difficulty when walking?


GO TO CRF7



CRF7. Does (care recipient) have difficulty eating?


GO TO CRF8



CRF8. Does (he or she) have difficulty using the toilet or getting to the toilet?


GO TO CRF9



21

CRF9. Does (care recipient) have difficulty keeping track of money or bills?


GO TO CRF10



CRF10. Does (he or she) have difficulty preparing meals?


GO TO CRF11



CRF11. Does (care recipient) have difficulty doing light housework, such as washing dishes or sweeping a floor?


GO TO CRF12



22

CRF12. Does (he or she) have difficulty doing heavy housework, such as scrubbing floors or washing windows?


GO TO CRF13



CRF13. Does (he or she) have difficulty taking the right amount of prescribed medicine at the right time?


GO TO CRF14



CRF14. Does (care recipient) have difficulty using the telephone?


GO TO CRF15



23

CRF15. Does (he or she) have difficulty driving an automobile?


24

Module G: Service and Information Needs

The next two questions ask you to think about what additional services and information may be helpful to you as a caregiver.

CRG1. In addition to the kinds and amounts of services you are receiving, (and the services that [care recipient’s name] is receiving), what additional or new kinds of help would be valuable to you as a caregiver?


1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

a. Housekeeping assistance for (care recipient’s name) .....

b. Shopping assistance for (care recipient’s name) ........

c. Transportation assistance for (care recipient’s name) .....

d. Assistance in making meals for (care recipient’s name) .................................................................

e. Assistance in bathing, dressing, grooming, toileting, feeding, and other personal care for (care recipient’s name) ..........................................

f. Adult daycare for (care recipient’s name) .................

g. Assistance in getting other family members involved in caring for (care recipient’s name) ...........

h. Assistance in administering and monitoring side effects of medicine for (care recipient’s name) etc ....

i. In-home respite care .............................................

j. Help with money management and financial advice .......

k. Other services ......................................................

(Specify) ___________________________________

__________________________________________

l. No additional help needed ......................................

25

CRG2. What additional or new kinds of information would be valuable to you as a caregiver? READ LIST. CHECK YES OR NO FOR EACH ONE.


1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

1 2 -7 -8

a. A help line/central place to call to find out what kind of help is available and where to get it ..............

b. Someone to talk to/counseling services or support groups .....................................................

c. Information about how to care for (care receiver’s name)’s condition or disability ..................

d. Information about changes in laws that might affect your situation ..............................................

e. Information about how to select a nursing home, group home, assisted living facility, or other care facility ..................................................

f. Information on how to pay for nursing homes, assisted living facilities, adult day care, and other services .......................................................

g. Information on how to deal with agencies (bureaucracies) to get services ...............................

h. Information on health insurance and/or long-term care insurance ......................................................

i. Other information not listed above ..........................

(Specify) ___________________________________

__________________________________________

l. No additional information needed ............................

POMP Final: Case Management Survey Instrument

(Telephone Version)

Office Use Only: Client ID: ____________________________________________________________________ Service Enrollment Date: ________________________________________________________ Date of Survey Administration: ____________________________________________________

Hello. My name is ____________________________. I am calling from the (name of AAA). I understand that you receive case management services. Your case manager is the person who sets up in-home services, such as homemaker or personal care services for you. The case manager also calls to check on how you are doing, or how you like your services. We would like to ask you a few questions about the person who coordinates/manages your services. The interview will take about 15 to 30 minutes. We are interested in the length of time you have received case management services and if the service has helped you. Your answers will help us make sure that the service meets your needs. Participation in the interview is voluntary and you may skip any question. Your answers will be kept confidential and will not influence the services that you receive.

Now we are going to talk about the case management service you receive from (agency/provider name).

CS1. When was the last time you received the case management service? Was it…



Refused ..................................................................... -7 Don’t Know ................................................................ -8 END INTERVIEW

CS2. Do you know how to contact your case manager when you need to?


CS2a. Are you the one who usually speaks to your case manager?

Yes ............................................................................ 1 GO TO CS3 No ............................................................................. 2 GO TO CS17

2

Always Usually

Sometimes

-Rarely Never Refused

Don’t Know

CS3. Does your case manager return your phone calls in a timely manner? 1 2 3 4 5 -7 -8

CS4. Does your case manager explain your services in a way that you can understand? 1 2 3 4 5 -7 -8

CS5. Does your case manager treat you with respect? 1 2 3 4 5 -7 -8

CS6. Does your case manager involve you in discussing and planning your services? 1 2 3 4 5 -7 -8

CS7. Does your case manager do a good job setting up care for you? 1 2 3 4 5 -7 -8

CS8. Does your case manager help you get services that you did not have before?


CS9. Is your situation better because of your case manager’s help?


Now I would like to ask you a few additional questions about the services you received through the case management program.

CS10. How long have you been receiving the case management services?


3

CS11. How would you rate the overall quality of the case management services you have received? Would you say …


CS12. Does your case manager help coordinate all the services you receive?


CS13. Are you able to select the services you receive?


CS14. As a result of receiving the case management services, do you have a better idea of where to get information about other services?


CS15. In general, would you say that the case management service has helped you?

Yes .................................................................................... 1 GO TO CS15a No ..................................................................................... 2

GO TO CS16 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

4

CS15a. How has the case management service helped you?

___________________________________________________________

___________________________________________________________

___________________________________________________________

CS16. Do you have any recommendations to improve the case management service?

Yes .................................................................................... 1 GO TO CS16a No ..................................................................................... 2

GO TO CS17 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

CS16a. What recommendations do you have for improving the case management service?

___________________________________________________________

___________________________________________________________

___________________________________________________________

CS17. Other than case management, what services do you receive? CIRCLE ALL THAT APPLY

Yes

No

Refused

Don’t Know

a. Transportation ...................................................... 1 2 -7 -8 b. Adult Day Services ................................................ 1 2 -7 -8 c. Personal Care Services .......................................... 1 2 -7 -8 d. Chore Services ..................................................... 1 2 -7 -8 e. Legal Assistance ................................................... 1 2 -7 -8 f. Information and Assistance .................................... 1 2 -7 -8 g. Home-Delivered Meals ........................................... 1 2 -7 -8 h. Homemaker/Housekeeper ...................................... 1 2 -7 -8 i. Medication Management ........................................ 1 2 -7 -8 j. Other .................................................................. 1 2 -7 -8

CS18. Are you satisfied with the services you receive?


5

CS19. Do the services you receive help you continue to live at home?


CS20. Are you receiving any other types of assistance such as ...

Yes

No

Refused

Don’t Know

Food Assistance/Food Stamps/SNAP ............................. 1 2 -7 -8 Energy Assistance ...................................................... 1 2 -7 -8 Medicaid ................................................................... 1 2 -7 -8 Housing Assistance .................................................... 1 2 -7 -8



1. Physical Functioning and Health Module

2. Social and Emotional Well-Being Module

3. Demographics Module

Thank you very much for your time and cooperation. Your responses have been very helpful to us.

POMP Final: Congregate Meals Survey Instrument

(Telephone Version)

Office Use Only:


Hello. My name is ____________________________. I am calling from the (name of AAA). I understand that you participate in the meal program. We would like to ask you a few questions about the meals that you receive. The interview will take about 15 to 30 minutes. We are interested in the length of time you have attended the meal program, what you like about the meals, and if the meals have helped you. Your answers will help us make sure that the service meets your needs. Participation in the interview is voluntary and you may skip any question. Your answers will be kept confidential and will not influence the services that you receive.

Now we are going to talk about the meal program you attend at (agency/provider name).

CM1. When was the last time you ate at the senior center or meal site?




CM2. How long have you been attending the meal program? Would you say…


CM3. How many days each week do you eat at the senior center or meal site?

|___|___| Number of Days Refused ............................................................................. -7 Don’t Know ........................................................................ -8

2


CM4. On the days when you eat at the meal site or senior center, how many meals do you usually eat?

|___|___| . |___| Refused ............................................................................. -7 Don’t Know ........................................................................ -8

CM5. On the days when you don’t eat at the meal site or senior center, how many meals do you usually eat?


CM6. Please consider all the food you eat in a day on the days you attend the meal program or senior center. What percentage of all the food you eat in a day is eaten at the meal program or senior center? Would you say…

Less than one-third ............................................................. 1 Between one-third and one-half ............................................ 2 About one-half .................................................................... 3 More than one-half .............................................................. 4 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

For the next set of questions, I will tell you the standard serving size for a particular food or group of foods. Please tell me how many total servings of each food or group of foods you usually eat each day.

CM7. One serving of fruit is one small piece of fruit, about one-half cup of chopped fruit, or one-half cup of juice.



3

CM8. One serving of potatoes is one small baked potato or one-half cup mashed or boiled potatoes.



CM9. One serving of vegetables is about one cup raw vegetables, one-half cup of cooked vegetables, or one-half cup of juice.



CM10. One serving of milk or yogurt, including soy milk or yogurt, is one cup of milk or yogurt. One serving of cheese is 1.5 slices or 1.5 ounces of cheese.



CM11. Beans, nuts, eggs, and tofu are sources of protein in the diet. One serving of beans or tofu is about one-half cup; one serving of peanut butter is two tablespoons; one serving of nuts is one ounce, and a serving of eggs is two eggs.



4

CM12. One serving of meat, chicken, turkey, or fish is a two to three ounce hamburger patty, chicken breast, or fish fillet.



CM13. One serving of bread is one piece of bread, one tortilla, or one small pancake.



CM14. Cereal, rice, pasta, and noodles are sources of grains in the diet. A serving of cereal is one cup of cold cereal or one-half cup hot cereal; a serving of rice, pasta, or noodles is one-half cup.

How many servings of cereal, rice, pasta, or noodles do you usually eat every day?


CM15. A serving of dessert is one-half slice of pie or cake or two medium cookies.



5

For the next set of questions, I am going to ask about foods or groups of foods that you eat when you attend the meal program or senior center. Please tell me if you usually eat each food or group of foods when you are at the senior center or meal program.

CM16. When you eat at the senior center or meal site, do you usually eat the fruit when it is provided?


CM17. When you eat at the senior center or meal site, do you usually eat the potatoes when they are provided?


CM18. When you eat at the senior center or meal site, do you usually eat the vegetables that are provided?


CM19. When you eat at the senior center or meal site, do you usually eat or drink the milk, cheese, yogurt, or soy milk, soy cheese, or soy yogurt that are provided?


CM20. When you eat at the senior center or meal site, do you usually eat the beans, nuts, eggs, or tofu when they are provided?


6

CM21. When you eat at the senior center or meal site, do you usually eat the meat, turkey, chicken, or fish that is provided?


CM22. When you eat at the senior center or meal site, do you usually eat the bread, tortillas, or pancakes that are provided?


CM23. When you eat at the senior center or meal site, do you usually eat the cereal, rice, pasta, or noodles when they are provided?


CM24. When you eat at the senior center or meal site, do you usually eat the dessert when it is provided?


Now I am going to ask about the services you receive at the meal program.

CM25. How would you rate the meal program overall? Would you say…


7

Think about all the foods that you receive from the meal program. Now tell me, how often are you satisfied…


Don’t Know

Not Applicable

CM26. With the way the food smells Would you say… 1 2 3 4 5 -7 -8 -9

CM27. With the way the food looks 1 2 3 4 5 -7 -8 -9

CM28. With the way the food tastes 1 2 3 4 5 -7 -8 -9

CM29. With the variety of foods 1 2 3 4 5 -7 -8 -9

CM30. That the hot foods are hot and cold foods are cold 1 2 3 4 5 -7 -8 -9

CM31. With the way the food is cooked 1 2 3 4 5 -7 -8 -9

Please answer the following questions about the meal program. Do services received at the meal program help you to…

CM32. Eat healthier foods ................................................

Yes 1

No 2

Refused

-7

Don’t Know

-8

CM33. Achieve or maintain a healthy weight ...................... 1 2 -7 -8

CM34. Improve your health ................................... ........... 1 2 -7 -8

CM35. Feel better ........................................................... 1 2 -7 -8

CM36. See your friends more often ................................... 1 2 -7 -8

CM37. Continue to live at home ........................................ 1 2 -7 -8

8

Please tell me: Don’t Yes No Refused Know

CM38. Do you like the meals you get from the meal program? 1 2 -7 -8

CM39. Would you recommend the meal program to a friend? 1 2 -7 -8

CM40. As a result of attending the meal program, do you have a better idea of where to get information about other services? ................................................... 1 2 -7 -8

CM41. While you are there, do you learn food safety tips for cooking and storing food?


CM42. While you are there, do you learn how to eat more healthful and nutritious foods?



CM43. Do you know that the congregate meal donation is voluntary?


CM44. How do you get to the meal program or senior center?

Public Transportation ........................................................... 1 Senior Center/Nutrition Program Transportation ...................... 2 Walk .................................................................................. 3 Drive ................................................................................. 4 Driven by someone ............................................................. 5 Other ................................................................................. 6 (Specify) __________________________________________ Refused ............................................................................. -7 Don’t Know ........................................................................ -8

9

CM45. Are there times when you have not been able to attend the meal program or senior center because you have no way to get there?


CM46. Do you always have enough money or food assistance/food stamps/SNAP to buy the food you need?


CM47. During the past month, did you have to choose between buying food or buying medication?


CM48. During the past month did you have to choose between buying food or paying your rent or utility bills?


CM49. On one or more days during the past month, did you skip meals because you had no food and no money or food assistance/food stamps/SNAP to buy food?


CM50. In general, would you say that the meal program has helped you?

Yes .................................................................................... 1 No ..................................................................................... 2 Refused ............................................................................. -7 GO TO CM51 Don’t Know ........................................................................ -8

10

CM50a. How has the meal program helped you?

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

CM51. Do you have any recommendations to improve the meal program?

Yes ............................................................................ 1 No ............................................................................. 2 GO TO ADDITIONAL

MODULES OR CLOSE

Refused ..................................................................... -7 Don’t Know ................................................................ -8

CM51a. What recommendations do you have for improving the service?

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________



1. Additional Services Received Module




Thank you very much for your time and cooperation. Your answers are very important to us in improving the meal program.

POMP Final: Home-Delivered Meals Survey Instrument

(Telephone Version)

Office Use Only:


Hello. My name is ____________________________. I am calling from the (name of AAA). I understand that you participate in the meal program. We would like to ask you a few questions about the meals that you receive. The interview will take about 15 to 30 minutes. We are interested in the length of time you have received home-delivered meals, what you like about the meals, and if the meals have helped you. Your answers will help us make sure that the service meets your needs. Participation in the interview is voluntary and you may skip any question. Your answers will be kept confidential and will not influence the services that you receive.

Now we are going to talk about home-delivered meals you receive from (agency/provider name).

HDM1. When was the last time you received a home-delivered meal?




HDM2. How long have you been receiving home-delivered meals? Would you say…


HDM3. How many days each week do you receive home-delivered meals?

|___|___| Number of Days Refused ............................................................................. -7 Don’t Know ........................................................................ -8

HDM3a. How many meals do you receive during an average week?

|___|___| Number of Meals Refused ...................................................................... -7 Don’t Know ................................................................. -8

2


HDM4. On the days that you eat the home-delivered meal, how many meals do you usually eat?


HDM5. On the days you don’t eat the home-delivered meal, how many meals do you usually eat?


HDM6. Think about the amount of food you eat from home-delivered meals. On the days you eat a meal from home-delivered meals, what proportion of all the food you eat in a day does this meal represent? Would you say…

Less than one-third ............................................................. 1 Between one-third and one-half ............................................ 2 About one-half .................................................................... 3 More than one-half .............................................................. 4 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

For the next set of questions, I will tell you the standard serving size for a particular food or group of foods. Please tell me how many total servings of each food or group of foods you usually eat each day.

HDM7. One serving of fruit is one small piece of fruit, about one-half cup of chopped fruit, or one-half cup of juice.



3

HDM8. One serving of potatoes is one small baked potato or one-half cup mashed or boiled potatoes.



HDM9. One serving of vegetables is about one cup raw vegetables, one-half cup of cooked vegetables, or one-half cup of juice.



HDM10. One serving of milk or yogurt, including soy milk or yogurt, is one cup of milk or yogurt. One serving of cheese is 1.5 slices or 1.5 ounces of cheese



HDM11. Beans, nuts, eggs, and tofu are sources of protein in the diet. One serving of beans or tofu is about one-half cup; one serving of peanut butter is two tablespoons; one serving of nuts is one ounce, and a serving of eggs is two eggs.



4

HDM12. One serving of meat, chicken, turkey, or fish is a two to three ounce hamburger patty, chicken breast, or fish fillet.



HDM13. One serving of bread is one piece of bread, one tortilla, or one small pancake.



HDM14. Cereal, rice, pasta, and noodles are sources of grains in the diet. A serving of cereal is one cup of cold cereal or one-half cup hot cereal; a serving of rice, pasta, or noodles is one-half cup.

How many servings of cereal, rice, pasta or noodles do you usually eat every day?


HDM15. A serving of dessert is one-half slice of pie or cake or two medium cookies.



5

For the next set of questions, I am going to ask about foods or groups of foods that you eat from your home-delivered meals. Please tell me if you usually eat each food or group of foods when you eat the home-delivered meals.

HDM16. When you eat the home-delivered meals, do you usually eat the fruit when it is provided?


HDM17. When you eat the home-delivered meals, do you usually eat the potatoes when they are provided?


HDM18. When you eat the home-delivered meals, do you usually eat the vegetables that are provided?


HDM19. When you eat the home-delivered meals, do you usually eat or drink the milk, cheese, yogurt, or soy milk, soy cheese, or soy yogurt that are provided?


HDM20. When you eat the home-delivered meals, do you usually eat the beans, nuts, eggs, or tofu when they are provided?


6

HDM21. When you eat the home-delivered meals, do you usually eat the meat, turkey, chicken, or fish that is provided?


HDM22. When you eat the home-delivered meals, do you usually eat the bread, tortillas, or pancakes that are provided?


HDM23. When you eat the home-delivered meals, do you usually eat the cereal, rice, pasta, or noodles when they are provided?


HDM24. When you eat the home-delivered meals, do you usually eat the dessert when it is provided?


Now I am going to ask about the quality of the meals you receive.

HDM25. How would you rate the quality of home-delivered meals overall? Would you say…


7

HDM26. Do the home-delivered meals arrive when expected?

Always ............................................................................... 1 Usually .............................................................................. 2 Sometimes ......................................................................... 3 Seldom .............................................................................. 4 Never ................................................................................ 5 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

Think about all the foods that you receive from home-delivered meals. Now tell me, how often are you satisfied…


Don’t Know

Not Applicable

HDM27. With the way the food smells Would you say… 1 2 3 4 5 -7 -8 -9

HDM28. With the way the food looks 1 2 3 4 5 -7 -8 -9

HDM29. With the way the food tastes 1 2 3 4 5 -7 -8 -9

HDM30. With the variety of foods 1 2 3 4 5 -7 -8 -9

HDM31. That the hot foods are hot and cold foods are cold 1 2 3 4 5 -7 -8 -9

HDM32. With the way the food is cooked 1 2 3 4 5 -7 -8 -9

8

Please answer the following questions about the home-delivered meals program. Do services received from the home-delivered meals program help you to…


HDM33. Eat healthier foods ............................................... 1 2 -7 -8

HDM34. Achieve or maintain a healthy weight ..................... 1 2 -7 -8

HDM35. Improve your health ............................................. 1 2 -7 -8

HDM36. Feel better .......................................................... 1 2 -7 -8

HDM37. Continue to live at home ....................................... 1 2 -7 -8

Please tell me: Don’t Yes No Refused Know

HDM38. Do you like the meals you get from the home-delivered meals? .............................................. .. 1 2 -7 -8

HDM39. Would you recommend the home-delivered meals to a friend? ...................................................... 1 2 -7 -8

HDM40. As a result of receiving home-delivered meals, do you have a better idea of where to get information about other services ................................... 1 2 -7 -8


HDM41. Do you know that the home-delivered meal donation is voluntary?


HDM42. Do you always have enough money or food assistance/food stamps/SNAP to buy the food you need?


9

HDM43. During the past month, did you have to choose between buying food or buying medication?


HDM44. During the past month did you have to choose between buying food or paying your rent or utility bills?


HDM45. On one or more days during the past month, did you skip meals because you had no food and no money or food assistance/food stamps/SNAP to buy food?


HDM46. In general, would you say that the home-delivered meals service has helped you?

Yes .................................................................................... 1 No ..................................................................................... 2 Refused ............................................................................. -7 GO TO HDM47 Don’t Know ........................................................................ -8

HDM46a. How has the home-delivered meals service helped you?

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

10

HDM47. Do you have any recommendations to improve the home-delivered meals service?

Yes ............................................................................ 1 No ............................................................................. 2 GO TO ADDITIONAL

MODULES OR CLOSE

Refused ..................................................................... -7 Don’t Know ................................................................ -8

HDM47a. What recommendations do you have for improving the service?

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________







Thank you very much for your time and cooperation. Your answers are very important to us in improving the home-delivered meals services.

POMP Final: Transportation Survey Instrument

(Telephone Version)

Office Use Only:


Hello. My name is ____________________________. I am calling from the (name of AAA). I understand that you receive transportation services. We would like to ask you a few questions about the services that you receive. The interview will take about 15 to 30 minutes. We are interested in the length of time you have received transportation services and whether the transportation services have been helpful. Your answers will help us make sure that the services meet your needs. Participation in the interview is voluntary and you may skip any question. Your answers will be kept confidential and will not influence the services that you receive.

Now we are going to talk about the transportation service you receive from (agency/ provider name).

TR1. When was the last time you used the transportation services?



Refused ..................................................................... -7 Don’t Know ................................................................ -8 END INTERVIEW

TR2. How long have you been receiving transportation services? Would you say…

6 months or less ................................................................. 1 More than 6 months, but less than 1 year .............................. 2 At least 1 year but less than 2 years ...................................... 3 2 to 5 years ........................................................................ 4 More than 5 years ............................................................... 5 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

2

TR3. How often do you use the transportation service?

5 or more times per week .................................................... 1 3 to 4 times per week .......................................................... 2 Once per week .................................................................... 3 1 to 2 times per month ........................................................ 4 Less than once per month .................................................... 5 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

TR4. In an average month, would you say you rely on this transportation service for:

Just a few of your local trips ................................................. 1 About 1/4 of all your local trips ............................................. 2 About 1/2 of all your local trips ............................................. 3 About 3/4 of all your local trips ............................................. 4 Nearly all of your local trips .................................................. 5 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

TR5. Which of the following best describes where you get on the vehicle?

Several blocks away ............................................................ 1 Down the block ................................................................... 2 My driveway/In front of my residence .................................... 3 The driver comes to my door ................................................ 4 At the senior center ............................................................. 5 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

3

For the next few questions, please tell me how frequently these statements apply to your overall experiences with (name of Transportation Service). Please select one of these seven responses: Always, Usually, Sometimes, Rarely, Never, Refused, Don’t Know).

Some- Don’t

TR6. The drivers pick me up when they are supposed to. Would you say ................................

Always

.. 1

Usually

2

times

3

Rarely

4

Never

5

Refused

-7

Know

-8

TR7. The drivers are polite. Would you say .................................. 1 2 3 4 5 -7 -8

TR8. The vehicles are easy to get into and out of. Would you say ........ 1 2 3 4 5 -7 -8

TR9. The vehicles are comfortable. Would you say ........................ 1 2 3 4 5 -7 -8

TR10. We arrive at our destinations on time. Would you say ............ 1 2 3 4 5 -7 -8

TR11. The trips take too long. Would you say .................................. 1 2 3 4 5 -7 -8

TR12. The transportation service takes me to the places I want or need to go. Would you say ............... 1 2 3 4 5 -7 -8

TR13. I get rides at the times and on the days I need them. Would you say .................................. 1 2 3 4 5 -7 -8

TR14. Do you need help getting into and out of your home?

Yes .................................................................................... 1 No ..................................................................................... 2

GO TO TR15 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

TR14a. Does the driver or aide help you get into and out of your home?


4

TR15. Do you need help getting into or out of the vehicle?

Yes .................................................................................... 1 No ..................................................................................... 2


TR15a. Does the driver or aide help you get into or out of the vehicle?


TR16. Do you get around more than you did before you had this service?


TR17. Would you recommend this transportation service to a friend?


TR18. Do the services you receive help you continue to live at home?


TR19. Next, how would you rate the transportation service that you received? Would you say...

Excellent ............................................................................ 1 Very Good .......................................................................... 2 Good ................................................................................. 3 Fair ................................................................................... 4 Poor .................................................................................. 5 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

5

TR20. Do you use the transportation service to get to: Don’t Yes No Refused Know

a. Doctors and health care providers ........................... 1 2 -7 -8 b. Shopping/Hairdresser ............................................ 1 2 -7 -8 c. Volunteer activities ............................................... 1 2 -7 -8 d. Senior center........................................................ 1 2 -7 -8 e. Lunch program ..................................................... 1 2 -7 -8 f. Friends, neighbors, and relatives ............................ 1 2 -7 -8 g. Social events and recreation activities ..................... 1 2 -7 -8 h. Clubs and meetings ............................................... 1 2 -7 -8 i. Religious services .................................................. 1 2 -7 -8 j. Work ................................................................... 1 2 -7 -8 k. Some place else? .................................................. 1 2 -7 -8 (Specify) ____________________________________

TR21. In general, would you say that the transportation service has helped you?

Yes .................................................................................... 1 No ..................................................................................... 2


TR21a. How has the transportation service helped you?

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

TR22. Do you have any recommendations to improve the transportation service?

Yes .................................................................................... 1 No ..................................................................................... 2


6

TR22a. What recommendations do you have for improving the service?

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

These next questions are about getting around outside your home.

TR23. Is there a car or other personal motor vehicle in working condition in this household?

Yes .................................................................................... 1 No ..................................................................................... 2


TR24. Do you ever drive that car?

Yes .................................................................................... 1 GO TO ADDITIONAL MODULES OR CLOSE No ..................................................................................... 2


TR25. Excluding taxi services, is public transportation service available in this community, such as a regular bus line, rapid transit, subway, or street car?

Yes .................................................................................... 1 No ..................................................................................... 2

GO TO ADDITIONAL MODULES OR CLOSE Refused ............................................................................. -7

Don’t Know ........................................................................ -8

TR26. Do you ever use public transportation?

Yes .................................................................................... 1 No ..................................................................................... 2


Don’t Know ........................................................................ -8

7

TR27. Do you have a physical, mental, or emotional condition that makes public transportation hard to use?

Yes .................................................................................... 1 No ..................................................................................... 2


Don’t Know ........................................................................ -8

TR27a. Do you need the assistance of another person to use public transportation?








Thank you very much for your time and cooperation. Your answers are very important to us in improving transportation services.

POMP Final: Additional Services Received Module

(Telephone Version)

Office Use Only:


SKIP QUESTION AS1 FOR CONGREGATE MEAL RESPONDENTS. SKIP QUESTION AS2 FOR HOME-DELIVERED MEAL RESPONDENTS. SKIP QUESTION AS4 FOR CASE MANAGEMENT RESPONDENTS. SKIP QUESTION AS5 FOR TRANSPORTATION RESPONDENTS.

I’d like to ask about additional help you may have received.

Yes No Refused Don’t Know

AS1. In the past year, have you attended a lunch program at a senior center or other meal site?

IF NEEDED: A lunch program, or Congregate Meals are meals provided in a group setting, such as at a senior center ........................................................ 1 2 -7 -8

AS2. In the past year, have you received Meals on Wheels?

IF NEEDED: Meals on Wheels or Home-Delivered Meals are meals that are usually delivered to eat at home ................................................................... 1 2 -7 -8

AS3. In the past year, have you received homemaker or housekeeping services?

IF NEEDED: Homemaker or housekeeping services are services that may include help with doing light housework, laundry, preparing meals or shopping ..... 1 2 -7 -8

AS4. In the past year, have you received case management services?

IF NEEDED: When someone receives case management, they have a case manager who may set up in-home services, such as homemaker or personal care services for them. The case manager may also call to check on how they are doing, or how they like the services ...................................... 1 2 -7 -8

AS5. In the past year, have you received transportation services?

IF NEEDED: Transportation is a bus or other vehicle that picks people up and takes them places such as the doctor, the senior center, or shopping

IF NEEDED: Includes recreational trips .................... 1 2 -7 -8

AS6. In the past year, have you received adult day care services?

IF NEEDED: Adult day care or adult day health is when people go to a place and spend the day ........... 1 2 -7 -8

2


AS7. In the past year, have you received personal care services?

IF NEEDED: Personal care services are help with care like dressing or bathing ................................... 1 2 -7 -8

AS8. In the past year, have you received chore services? IF NEEDED: Chore services help with heavier

housecleaning and yard work .................................. 1 2 -7 -8

AS9. In the past year, have you received legal assistance? IF NEEDED: Legal assistance may help with

making a will or understanding a bill and other legal matters.

IF NEEDED: Remember, we are talking about services received from (agency/provider name) ........ 1 2 -7 -8

AS10. In the past year, have you received information and assistance services?

IF NEEDED: Information and assistance helps people find out about services that are available to them.


AS11. Do you have a nutrition counselor who gives individual advice on what you should eat based on general health, chronic conditions, medications, and your usual food choices?


AS12. Have you received health screenings such as blood pressure checks or mammograms other than those from your own doctor?


AS13. Have you received flu shots, pneumonia shots, or other immunizations other than those from your own doctor?


AS14. Have you taken exercise or fitness classes or do you use the exercise equipment at a senior center or other program for older adults?


3


AS15. Do you receive help managing your medications, understanding how much to take, how often and whether it works with your other medicines?

IF NEEDED: Does not include help from family or friends. This is help from (agency/provider name). .... 1 2 -7 -8

AS16. In the past year, have you received help getting benefits, such as food stamps, Medicaid, SSI, or Social Security? .................................................... 1 2 -7 -8

AS17. Overall, how would you rate the group of services you receive? Would you say…


AS18. Are you receiving any other types of assistance, such as…


a. Food Assistance/Food Stamps/SNAP ................... 1 2 -7 -8 b. Energy Assistance ............................................ 1 2 -7 -8 c. Medicaid .......................................................... 1 2 -7 -8 d. Housing Assistance ........................................... 1 2 -7 -8

Now, I would like to ask about how these services help you.

AS19. As a result of the services you receive, are you able to live independently?


AS20. As a result of the services you receive, are you better able to care for yourself?


GO TO NEXT MODULE OR CLOSE

POMP Final: Demographics Module

(Telephone Version)

Office Use Only:



D1. ASK IF NOT OBVIOUS. What is your gender?

Male .................................................................................. 1 Female .............................................................................. 2

D2. In what year were you born?

|___|___|___|___| Year Refused ............................................................................. -7 Don’t Know ........................................................................ -8

D3. What is your highest education level?

Less than high school diploma .............................................. 1 High school diploma ............................................................ 2 Some college, including associate degree ............................... 3 Bachelor’s degree ................................................................ 4 Some post-graduate work or advanced degree ....................... 5 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

D4. Are you Spanish, Hispanic or Latino?


D5. What is your race? MARK ALL THAT APPLY.

a. American Indian or Alaskan Native ................................... 1 b. Asian ............................................................................ 2 c. Black or African-American ............................................... 3 d. White/Caucasian ............................................................ 4 e. Native Hawaiian/Other Pacific Islander.............................. 5 f. Other Race .................................................................... 6 g. Refused ........................................................................ -7 h. Don’t Know ................................................................... -8

2

D6. What is your marital status?

Now married ....................................................................... 1 Widowed ............................................................................ 2 Divorced ............................................................................ 3 Separated .......................................................................... 4 Never married .................................................................... 5 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

D7. Where is your home located? Would you say…

In a city ............................................................................. 1 In a suburban area .............................................................. 2 In a rural area .................................................................... 3 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

D8. We’d like to ask about who lives in your household. Do you…

Yes No a. Live alone ............................................................ 1 2 IF “Yes,”

GO TO D10 b. Live with your spouse ............................................ 1 2 c. Live with your children .......................................... 1 2 d. Live with other relatives ......................................... 1 2 e. Live with domestic partner ..................................... 1 2 f. Live with non-relatives other than domestic partner .. 1 2


D9. How many people live in your household, including yourself?

|___|___| Number of Household Members Refused ............................................................................. -7 Don’t Know ........................................................................ -8

3

D10. Thinking about the total combined income from all sources for all persons in your household, including income from jobs, Social Security, retirement income, public assistance, and all other sources was your total household annual income during the last calendar year above or below $20,000?

At or below $20,000 ($1,666 per month or less) ..................... 1 GO TO D10a Above $20,000 ($1,667 per month or more) .......................... 2 GO TO D10b Refused ............................................................................. -7 GO TO CLOSE Don’t Know ........................................................................ -8

D10a. Which category best describes your total household annual income during the last calendar year? Would you say…

$5,000 or less ($417 or less per month) ......................... 1 $5,001 - $10,000 ($418 to $833 per month) .................. 2 $10,001 - $15,000 ($834 to $1,250 per month) .............. 3 GO TO CLOSE $15,001 - $20,000 ($1,251 to $1,666 per month) ........... 4 Refused ...................................................................... -7 Don’t Know ................................................................. -8

D10b. Which category best describes your total household annual income during the last calendar year? Would you say…

$20,001 - $25,000 ($1,667 to $2,083 per month) ........... 1 $25,001 - $30,000 ($2,084 to $2,500 per month) ........... 2 $30,001 - $35,000 ($2,501 to $2,917 per month) ........... 3 $35,001 - $40,000 ($2,918 to $3,333 per month) ........... 4 $40,001 - $50,000 ($3,334 to $4,167 per month) ........... 5 Over $50,000 ($4,168 per month or more) ..................... 6 Refused ...................................................................... -7 Don’t Know ................................................................. -8

GO TO CLOSE.

POMP Final: Physical Functioning and Health Module

(Telephone Version)

Office Use Only:


These next few questions are about your health.

PF1. In general, would you say your health is:


PF2. Do you use any of the following aids? If “Yes,” have you used them

for 6 months or longer?

Yes No Refused Don’t Know Yes No Refused

Don’t Know

PF2a. A cane, crutches, or a walker ................ 1 2 -7 -8 1 2 -7 -8

PF2b. A wheelchair, electric scooter, etc ......... 1 2 -7 -8 1 2 -7 -8

PF2c. A hearing aid ...................................... 1 2 -7 -8 1 2 -7 -8

PF2d. Other (e.g., grab bar, shower chair, shower bench, etc.) ............................ 1 2 -7 -8 1 2 -7 -8

PF3. About how many different prescription medications do you take every day?

|___|___| Refused ............................................................................. -7 Don’t Know ........................................................................ -8

PF4. In the past 12 months, did you have to stay overnight in a nursing home or rehabilitation center?


2

PF5. In the past 12 months, did you have to stay overnight in a hospital?


PF6. In the past 12 months, did you receive treatment in an emergency room?


3

We would like to ask you about some common activities of daily life and whether you usually need assistance with them. This does not include the effects of temporary conditions. If you use an aid or assistive device, please indicate if you still have difficulty when using the aid.

Because of a physical or mental health condition, do you have difficulty...

If “Yes,” do you need the help of another person?

Yes No Refused Don’t Know Yes No Refused

Don’t Know

PF7. Getting around INSIDE the home 1 2 -7 -8 1 2 -7 -8

PF8. Getting around OUTSIDE the home, for example to shop or visit a doctor’s office 1 2 -7 -8 1 2 -7 -8

PF9. Getting in or out of a bed or a chair 1 2 -7 -8 1 2 -7 -8

PF10. Taking a bath or shower 1 2 -7 -8 1 2 -7 -8

PF11. Dressing 1 2 -7 -8 1 2 -7 -8

PF12. Walking 1 2 -7 -8 1 2 -7 -8

PF13. Eating 1 2 -7 -8 1 2 -7 -8

PF14. Using or getting to the toilet 1 2 -7 -8 1 2 -7 -8

PF15. Keeping track of money or bills 1 2 -7 -8 1 2 -7 -8

PF16. Preparing meals 1 2 -7 -8 1 2 -7 -8

PF17. Doing light housework, such as washing dishes or sweeping a floor 1 2 -7 -8 1 2 -7 -8

PF18. Doing heavy housework, such as scrubbing floors and washing windows 1 2 -7 -8 1 2 -7 -8

PF19. Taking the right amount of prescribed medicine at the right time 1 2 -7 -8 1 2 -7 -8

PF20. Using the telephone 1 2 -7 -8 1 2 -7 -8

4

Now I would like to ask about medical conditions you may have.

PF21. Have you ever been told by a doctor, nurse, or other health care professional that you have...


a. Arthritis or rheumatism ............................................ 1 2 -7 -8 b. High blood pressure or hypertension .......................... 1 2 -7 -8 c. A heart attack, coronary heart disease, angina,

congestive heart failure, or other heart problems ........ 1 2 -7 -8 d. High cholesterol ...................................................... 1 2 -7 -8 e. Diabetes or high blood sugar .................................... 1 2 -7 -8 f. Allergies, asthma, emphysema, chronic bronchitis,

or other breathing or lung problems .......................... 1 2 -7 -8 g. Cancer or a malignant tumor, excluding minor

skin cancer ............................................................. 1 2 -7 -8 h. Stroke ................................................................... 1 2 -7 -8 i. Anemia .................................................................. 1 2 -7 -8 j. Osteoporosis........................................................... 1 2 -7 -8 k. Kidney disease ........................................................ 1 2 -7 -8 l. Eye or vision conditions such as glaucoma, cataracts,

macular degeneration or other medical conditions [Does not include only wears glasses or contacts.] ...... 1 2 -7 -8 m. Oral health/tooth or mouth problems ......................... 1 2 -7 -8 n. Hearing problems .................................................... 1 2 -7 -8 o. Emotional, nervous, or psychiatric problems ............... 1 2 -7 -8 p. Memory related disease such as Alzheimer’s or

dementia ............................................................... 1 2 -7 -8 q. Seizures or epilepsy ................................................ 1 2 -7 -8 r. Parkinson’s ............................................................. 1 2 -7 -8 s. Persistent pain, aching, stiffness or swelling around

a joint? [Includes broken bones and sprained muscles, and bad backs, knees, shoulders, etc.] ......... 1 2 -7 -8

t. Multiple Sclerosis .................................................... 1 2 -7 -8 u. A serious problem with urinary incontinence ............... 1 2 -7 -8 v. Something else? ..................................................... 1 2 -7 -8 Please Specify ____________________________________________________

GO TO NEXT MODULE OR CLOSE.

POMP Final: Social and Emotional Well-Being Module

(Telephone Version)

Office Use Only:


These next few questions are about your overall social and emotional well-being.

SE1. During an average week, how many days are you in touch by phone, Internet, or in person with a friend, neighbor, or relative who does not live with you?

None ................................................................................. 1 One day ............................................................................. 2 Two days ........................................................................... 3 Three days ......................................................................... 4 Four days ........................................................................... 5 Five days ........................................................................... 6 Six days ............................................................................. 7 Every day ........................................................................... 8 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

SE2. Thinking about how often you are in touch with friends, neighbors, and relatives is this ...

Not enough (Would like to do more) ...................................... 1 About enough ..................................................................... 2 Too much ........................................................................... 3 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

SE3. During an average week, how many days do you leave home to go to a movie, sports event, club meeting, class, or place of worship?

None ................................................................................. 1 One day ............................................................................. 2 Two days ........................................................................... 3 Three days ......................................................................... 4 Four days ........................................................................... 5 Five days ........................................................................... 6 Six days ............................................................................. 7 Every day ........................................................................... 8 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

SE4. Regarding your present social activities, do you feel that you are doing ...

Not enough (Would like to do more) ...................................... 1 About enough ..................................................................... 2 Too much ........................................................................... 3 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

2

SE5. In general, how would you describe your emotional well-being?


SE6. During the past 30 days, how often have you had difficult or painful feelings such as stress, grief, worry, anger or loneliness?

Always ............................................................................... 1 Usually .............................................................................. 2 Sometimes ......................................................................... 3 Rarely ................................................................................ 4 Never ................................................................................ 5 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

SE7. During the past 30 days, to what extent have feelings such as stress, grief, worry, anger or loneliness interfered with your normal social activities with family, friends, neighbors, or groups?

Always ............................................................................... 1 Usually .............................................................................. 2 Sometimes ......................................................................... 3 Rarely ................................................................................ 4 Never ................................................................................ 5 Refused ............................................................................. -7 Don’t Know ........................................................................ -8

GO TO NEXT MODULE OR CLOSE.